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OBSTETRICAL TRANSACTIONS, 

VOL. XXXVI. 



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TRANSACTIONS 



OT THB 



OBSTETRICAL SOCIETY 



I c^-ly^o 



LONDON. 

VOL. XXXVI. 
FOB THE YEAB 1894. 

WITH A LIST OF OFFICERS, FKtLOWS, ItTO. 




BDITBD BT 

WILLIAH DUNCAN, M.D., Sbhiob Sbobbtabt,. 

AND 

PEEOT BOULTON, M.D. 



LONDON: 

LONGMANS, GEEEN, AND CO. 

1895. 



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PBIKTBD BT ADLABP AK]> BON, 
BABTHOLOMBW 0L08B, B.C., ABD 20, HABOYBB 8QUABB, W. 



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OBSTETRICAL SOCIETY OF LONDON. 



OFFICERS FOB 1896. 
Blbotbd Pbbkuakt 6th, 1895. 



PBBSIDBirT. 



VIOl- 
PUBIDBirTS. 



TBXA81TB1B. 

CHAIBMAN 01 

ZHBB0ABD70B 

IHBIXAMINATION 

OllODWiyBS. 

HOKOBABT 

8BCBBTABIB8. 

HOKOBABT 

LIBBABIAK. 



CHAMPNETS,FEANCIS HBNBT,M.A.,M.D. 

DUNCAN, JAMES, M.B. 
GALTON, JOHN H., M.D. 
HOBBOCKS, PETEB, M.D. 
NESHAM, THOMAS CABGULL, M.D. (New- 
ca8tle-on-T7ne). 

POTTEB, JOHN BAPTI8TE, M.D. 
CTJLLINGWOBTH, CHABLBS JAMES, M,D. 



BX-OF7I0IO 

MBMBBBS 

OF COJTSCIL. 



OTHXB 
HXMBEBS 

OF ooinroiL. 



} 

/ DUNCAN, WILLIAM, M.D. 
I DAKIN, W. E., M.D. 

} PHILLIPS, JOHN, M.A., M.D. 

OLDHAM, HENRY, M.D. (TruiU*). 
BARNES, ROBERT, M.D. (2V*rt«). 
HICKS, JOHN BRAXTON, M.D., P.E.S. 
PHIESTLET, Sib WILLIAM O., M.D. 
WEST, CHARLES, M.D. 
PLATFAIR, WILLIAM S., M.D. 
GERVIS, HBNRT, M.D. 
HERMAN, Q. ERNEST. M.B. 
WELLS, Sib THOS. SPENCER, Babt. (Tnutee). 
ADAMS, THOMAS RUTHERFORD, M.D. 

(Croydon). 
BEACH. FLETCHER, M.D. (EingBtonHiU). 
BOXALL. ROBERT, M.D. 
DONALD, ARCHIBALD, M.A., M.D. (Man- 

cheater). 
DRAOE, LOVELL, M.D. (Hatfield). 
FURNER, WILLOUGHBT (Brighton). 
GOW, WILLIAM JOHN, M.D. 
GRIFFITH, WALTER S. A.. M.D. 
HARPER, GERALD S., M.B. 
HOLMAN, C0N8TANTINE, M.D. 
MALCOLM, JOHN D., M.B., CM. 
PEARSON, DAVID RITCHIE, M.D. 
POLLOCK, WILLIAM RIVERS, M.B., B.C. 
RBMFRT, LEONARD, M.A., M.D. 
SALTER, JOHN HENRT (Kelvedon). 
SUTTON, JOHN BLAND. 
TARGETT, JAMES HENRY, M.B., B.8. 
TATE, WALTER W. H., M.B. 



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LIST OF PAST PRESIDENTS OF THE 
SOCIETY. 



1869 EDWARD EIGBT, M.D. 

1861 WILLIAM TTLEE SMITH, M.D. 

1868 HENBT OLDHAM. M.D. 
1865 BOBEBT BABNES, M.D. 
1867 JOHN HALL DAVIS, M.D. 

1869 GBAILT HEWITT, M.D. 

1871 JOHN BEAXTON HICKS, M.D., P.E.S. 

1878 BDWABD JOHN TILT, M.D. 

1875 Sib WILLIAM OVEBBND PBIESTLBT, M.D. 

1877 CHABLES WEST, M.D. 

1879 WILLIAM S. PLATPAIB, M.D. 

1881 J. MATTHEWS DUNCAN, M.D., P.B.S. 

1888 HENBT GEBVIS, M.D. 

1885 JOHN BAPTISTE POTTEE, M.D. 

1887 JOHN WILLIAMS, M.D. 

1889 ALPBBD LEWIS GALABIN, M.D. 
1891 JAMES WATT BLACK, M.D. 
1893 G. EBNEST HEBMAN, M.R 



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REFEREES OF PAPERS FOR THE YEAR 1895 
Appointed bt the Ooxtsoil. 



BLACK, J. WATT, M.D. 

BOULTON, PERCY, M.D. 

CULLIN6W0RTH, CHARLES JAMES, M.D. 

DORAN, ALBAN. 

OALABIN, ALFRED LEWIS. M.A., M.D. 

OERVIS, HENRY, M.D. 

HERMAN, 6. ERNEST, M.B. 

HICKS, JOHN BRAXTON, M.D., F.R.S. 

HORROCKS, PETER, M.D. 

LAWRENCE, A. E. AUST. M.D., Bristol. 

MALINS, EDWARD, M.D., Birmingham. 

POTTER, JOHN BAPTISTE, M.D. 

PRIESTLEY, Sib WILLIAM 0., M.D. 

STEPHENSON, WILLIAM, M.D., Aberdeen. 

SUTTON, J. BLAND. 

WELLS, Sib T. SPENCER, Babt. 

WILLIAMS, Sib JOHN. Babt., M.D. 



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STANDING COMMITTEES. 



BOARD FOR THE EXAMINATION OF MIDWIVES. 



CHAIBMAB. 



KX-OPPIOIO. 



CTJLLINGWOBTH. CHARLES JAMES, M.D. 

LEWERS, ARTHUR H. N., M.D. 

ROUTH, AMAND, M.D. 

HANDFIELD-JONES. M., M.D. 
( CHAMPNBT8, FRANCIS ) p,„.iA«./ 
\ HBNRT, M.A., M.D., j ^rendent. 
i DUNCAN, WILLI AM, M.D.. ^ ^^ 9^^, 
( DAKIN. W. R., M.D., j ^'^- ^^• 



LIBRARY COMMITTEE. 



Bx-orricio.- 



DORAN, ALBAN. 
HERMAN, Q. ERNEST, M.B. 
TAIT, EDWARD S., M.D. 
rCHAMPNETS, FRANCIS | p..„v^. 
HENRY, M.A., M.D., \ President 

POTTER, JOHN B., M.D., Treasurer. 
DUNCAN, WILLI AM,M.D., | „^ q^,. 
DAKIN, W. R., M.D., \ ^'^- ^'"■ 

PHILLIPS, JOHN, M.A., M.D., Hon. Lib. 



PUBLICATION COMMITTEE. 



ix-ornoio. 



BLACK, J. WATT, M.D. 
GERVIS, HENRY, M.D. 
HERMAN, G. ERNEST, M.B. 
PLAYFAIR, WILLIAM S., M.D. 
POTTER, JOHN BAPTISTE, M.D. 
WILLIAMS. Sni JOHN, Babt., M.D. 
CHAMPNEYS, FRANCIS ) p„,^^, 
HENRY, M.A., M.D., ) "^♦^""'«"- 

BOULTON, PERCY, M.D., EdUor. 
DUNCAN, WILLIAM, M.D., I x^^ „ , 
^DAKIN, W. R., M.D., J ^'^^ ^""- 



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HONORARY LOCAL SECRETARIES. 



JoNBS, Evan Aberdare. 

6088, T. BiDDiJLPH Bath. 

Sharpin, Henry W Bedford. 

Corey, Thomas C. S., M.D Belfast. 

Halins, Edward. M.D Birmingham. 

FuRNER, WiixoUGHBY Brighton. 

BiODEN, Geokgb Canterbury. 

Lawrence, A. E. Aust, M.D Clifton. 

Brajthwaite, James, M.D Leeds. 

Thompson, Joseph Nottingham. 

Walker, Thomas James, M.D Peterboroagh. 

Walters, James Hopkins Reading. 

Wilson, Robert James StLeonard's. 

Keeling, James Hurd, M.D SheflSeld. 

BuRD, Edward, M.D., CM Slirewsbury. 

Childs, Christopher, M.D Weymouth. 

Branpoot, Arthur Mudge, M.B Madras. 

Perrigo, James, M.D Montreal, Canada. 

Takaki, Kanaheiro Japan. 



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OBSTBTRIOAL SOCIETY OF LONDON. 



tbustees of the society 8 property. 

Henry Oldham, M.D. 
Robert Barnes, M.D. 
Sir Thomas Spencer Wells^ Bart. 



HONORARY FELLOWS. 

BRITISH SUBJECTS. 



Elected 

1871 KiDD, George H., M.D., F.R.C.S.I., Obstetrical Surgeon 

to the Coombe Lying-in Hospital ; dO» Merrion square 

south, Dublin. 

1892 Lister, Sir Joseph, Bart., F.R.S., LL.D., 12, Park crescent^ 
Portland place, N.W. 

1892 Turner, Sir William, F.R.S., Professor of Anatomy, 
University of Edinburgh ; 6, Eton terrace, Edinburgh. 

1870 West, Charles, M.D., F.R.C.P., Foreign Associate of 
the Academy of Medicine of Paris ; 4, Evelyn mansions^ 
Carlisle place, Victoria street, S.W. Pre9» 1877-8. 

FOREIGN SUBJECTS. 

1895 GusSEROW, Professor, Berlin. 

1866 Lazarbwitch, J., M.D., Professor Emeritus and Physician 
to the Maximilian Hospital ; Spaskaja, 2, St. Peters- 
burg. Tran9. 3. 

1862 LusK, William Thompson, M.D., Professor of Obstetricsy 
Bellevue Hospital Medical College, New York. 



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XU FELLOWS OF THE SOCIETY. 

Meeted 

1864 Pajot, Ch. M.D., late Professor of Midwifery to the Faculty 
of Medicine, Paris. 

1877 Stoltz, Professor, M.D. Nancy. 

1891 Tabnibr, SxiPHiLNE, M.D.y Professor of Obstetrics, Facult6 
de M^decine de Paris ; 15, Rue Duphot, Paris. 

1872 Thomas, T. Oaillard, M.D., Professor of Obstetrics in the 
College of Physicians and Surgeons ; 296, Fifth 
avenue. New York, 

1862 VntCHOW, Rudolf, M.D., Professor of Pathological Ana- 
tomy in the University of Berlin. 

1895 VON WiNCKBL, Professor, Munich. 



CORRESPONDING FELLOWS. 

1873 Mabtin, a. E., M.D., Berlin. Trans. 1. 

1876 BuDiN, P., M.D., 129, Boulevard St. Germain, Paris. 
Trans. 1. 

1876 Chadwiok, James R., M.A., M.D., Physician for Diseases 
of Women, Boston City Hospital ; Clarendon street, 
Boston, Massachusetts, U.S. 



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ORDINAEY FELLOWS. 

1894. 



Those marked thns (*) have paid the Compofition Fee in lieu of further 
annual subBcriptions. 

Thoae marked thus (f) reside beyond the London Postal District. 

The letters OJP. are prefixed to the names of the *' Original Fellows '' of the 

Society. 



Sleeted 

1890t AoKBBLBT, RiOHABD, M.B., B.S.OzoD., St. DmiBtan'B, 

Sutton, Surrey. 
1891 Adams, Chablbs Edmund, 227, Gipsy road. West Norwood, 

S.E. 
1884t Adams, Thomas Rutubbfobd, M.D., 119, North End, 

West Croydon. Council, 1894-5. 
1890 Addinsell, Augustus W., M.B., C.M.Edin., 30, Ashburn 

place, South Kensington, S.W. 
1893t Aloock, Bichabd, M.B., Burlington crescent, Ooole. 
1883*tALLAN, Robbbt John, L.R.C.P.Ed., The Bungalow, 

Dulwich hill, Sydney, New South Wales. [Per 

Alexander Allan, Esq., Olen House, The Valley, Scar- 
borough.] 
1890t Allan, Thomas S., L.R.C.P. & S.Ed., 13, Queen's road, 

Coventry. 
187dt Allbn, Henbt Mabcus, F.R.C.P.Ed., 20, Regency square, 

Brighton. 
1887 Ambbose, Robbbt, B.A., L.R.C.P. & S.Ed., 1, Mount place, 

Whitechapel road, E. 
1878 Andbbson, Izbtt William, M.D., 10, St. Leonard's road, 

Ealing, W. Trans. 1. 
1875 Andbbson, John Fobd, M.D., CM., 41, Belsize park, N.W. 

Council, 1882. 
1859 Andbews, Jambs, M.D., Everleigh, Green hill, Hampstead» 

N.W. Council, 1881. 



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XIV FELLOWS OF THE SOCIETY. 

Elected 

1890t Anson, George Edwabd, M.A., M.D.CanUb., The Terrace, 
Wellington, New Zealand. 

1870*tApPLETON, Robert Carlisle, The Bar House, Beverley. 

1884 Appleton, Thomas A., 46, Britannia road, Fulham, S.W. 

1883t Archibald, John, M.D., 2, The Avenue, Beckenham. 

1871 Aroles, Frank, L.R.C.P.Ed., Hermon Lodge, Wanstead, 
Essex, E. Council, 1886-7. 

1888t Armstrong, Jambs, M.B. Edin., 84, Kodney street, Liver- 
pool. 

1886 Ashe, William Percy, L.R.C.P. Lond., 41, Sloane 

gardens, S.W. 

1892t Ashworth, James Henry, M.D. St. And., Halstead, Essex. 

1887 Bailey, Henry Frederick, The Hollies, Lee terrace, Lee, 

S.E. 

1887t Baker, Oswald, L.R.C.P. &S. Ed., Surgeon-Major, Indian 
Army, Rangoon, India. 

1880t Balls- Headley, Walter, M.D., F.R.C.P., 4, Collins street 
east, Melhourne, Victoria. 

1869* Bantock, George Granville, M.D., Surgeon to the 
Samaritan Free Hospital ; 12, Granville place, Portman 
square, W. Council, 1874.6. TranM, 2. 

1893t Barber, Richard Henry, L.R.C.P. & S.Edin., 505, 
Williams avenue, Albina, Portland, Oregon, U.S.A. 

1886»tBARBOUR, A. H. FREELAND,M.D.Edin., 4, Charlotte square, 
Edinburgh. 

O.F.* Barnes, Robert, M.D., F.R.C.P., Consulting Obstetric 
Physician to St. George's Hospital; 7> Queen Anne 
street, Cavendish square, W. Fiee-Pres. 1859-60. 
Council, 1861-2, 1867. Treas. 1863-4. Pres, 
1865-6. Trans, 32. Trustee. 

1875 Barnes, R. S. Fancourt, M.D., F.R.S.Edin., Senior 
Physician to the British Lying-in Hospital ; 7, Queen 
Anne street. Cavendish square, W. Council, 1879-81. 
Board Exam, Midwives, 1880-2. Trans. 2. 



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FBLL0W8 OF THB SOCIETY. XV 

Elected 

1894 Babnbs, Thomas H., M.D. St. And., 69, Seymour street, W. 

1884 Babraolough, Robert W. S., M.D. 

1886t Babbington, Poubnbss, M.B.Edin., F.B.C.S.Eng. (c/oThe 
Commercial Bank of Sydney, 18, Birchin lane, E.G.). 

1894t Babtlett, Hedley C, L.B.C.P.Lond., High street. 
Saffron Walden. 

1891 Babton, Edwin Alfred, L.B.C.P.Lond., 35, Cheniston 

Gardens, Kensington, W. 

I892t Barton,Fbanoi8 Alexander, B.A. Cantab. ,L.R.C.P.Lond., 
Oonville House, Penge road, Beckenham. 

1887 Barton, Henry Thomas, 61, Harford street, E. 

1887t Barton, William Edwin, L.R.C.P. Lond., Staunton-on- 
Wye, near Hereford. 

1861*tBABTBUM, John S., F.R.C.S., Surgeon to the Bath General 
Hospital; 13, Gay street, Bath. Council^ 1877-9. 

1893i* Batohelob, Febdinand Campion, M.D.Durh., Dunedin, 
New Zealand. 

1873 Bate, Geoboe Paddock, M.D., 412, Bethnal Green road» 
N.E. ; and 2, Northumberland Houses, King Edward 
road. Hackney. Cauneil, 1882-4. 

1871t Beach, Fletcheb, M.B., F.R.C.P., Winchester House, 
Kingston hill, Surrey; and 64, Welbeck street, W. 
Council, 1898-5. 

1871 Beadles, Arthur, Park House, Dartmouth Park, Forest 
hUl, S.E. 

1893 Beale, Arthur A., M.B., C.M.Glas., 181, Southampton 
street, Camberwell, S.E. 

1892 Bbauchamp, Sydney, M.B., B.C.Cantab., 146, Cromwell 

road, S.W. 

l866*tBELCHBR, Henry, M.D., 28, Cromwell road. West Brighton. 

1871*tBELL, Robebt, M.D. Glasg., 29, Lyncdoch street, Glasgow. 

1880t Bbninoton, Robebt Cbewdson, M.D. Durh., 59, Osborne 
road, Newcastle-on-Tyne. 



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Xn FELLOWS OF THE SOCIETY. 

Efeeted 

lS93f Bbnj AFIELD, William Baenett, M.B., C.M.Ediii.» Bletch- 
enden, Lower Edmonton. 

I889t Benson, Matthew, M.D.Braz., 35, Dicconson street, 
Wigan. 

1894 Beekelby, Oeoeob A. H. C, B.A., M.B., B.C.Cantab., 
72, Belgrave road, S.W. 

1893 Bebnau, Heney Feedinand, L.B.C.P.Lond. 

I893t Beebiboe, William Alfbed, Oakfield, RedhilL 

1883 Bebtolaoci, J. Hbwetson, Beaufort House, Enaphill, 
Surrey. 

1889t Best, William James, 1, Cambridge terrace, Dover. 

l893*tBETENS0N, WiLLUM Betenson, L.R.C.P.Loud., Bungay, 
Suffolk. 

1894 Betenson, Woodley Daniel, L.RC.P.Lond., 26, Caver- 

sham road, N.W. 

1893t Betts, Fbedebiok Bebnabd, L.B.C.P.Lond., Autofagasta, 
Chili, South America. 

189 If Beyille, Fbedebiok Wells, L.B.C.P.Lond., The Firs, 
Pahice road. East Molesey. 

1887*tBii>EN, Chaeles Waltee, L.R.C.P.Lond., Lazfield, Fram- 
lingham. 

1879 Bioos, J. M., Hillside, Child's hill, N.W. 

1892 BiBD, Matthew Mitchell, M.D., B.S.Durh., St. Mary's 
Hospital, W. 

I889t BissHOPP, Fbancis Bobeet Beyant, M.A., M.B., 
B.C.Cantab., Belvedere, Mount Pleasant, Tunbridge 
WeUs. 

1890 Black, Oeobge, M.B., B.S.Lond., 50, Cazenove road, 
Stamford hill, N. 

1868* Black, James Watt, M.A., M.D., F.B.C.P., Obstetric Physi- 
cian to the Charing Cross Hospital ; 15, Clarges street, 
Piccadilly, W. CauneU, 1872-4. Fiee^Pres. 1885-6. 
Chairman^ Board Exam. Midwives, 1887-90. Pret. 
189U2. 



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FELLOWS OF THE SOCIETY. XVll 

Elected 

1893 Blackeb, Oeobge Francis, M.D., B.S.Lond., F,R.C.S.» 

Assistant Obstetric Physician to University College 
Hospital ; 20, Weymouth street, W. 

1861*tBLAKE, Thomas William, Hurstboume, Boomemoath, 
Hants. 

1872*tBLAND, Oeoboe, Consulting Surgeon to the Macclesfield 
Infirmary ; Pottergate Lodge, Lincoln. 

1887 Bluett, Oeokge Mallack, L.R.C.P.Lond., 11, Addison 
terrace, Notting hill, W. 

1894 Bodillt, Eeoinald Thomas H., L.R.G.P.Lond., Wood- 

bury, High road, South Woodford. 

1892 Bond, William Abthur, M.A., M,D., B.S.Cantab., 9, Duke 
street, St. James's, S.W. 

1883 Bonnet, William Augustus, M.D., 100, Elm park gardens, 
Chelsea, S.W. 

1894t BoRCHBBDS, Walter Meent, M.R.C.S., L.R.C.P., 
Worcester, Cape Colony. 

1893t BoswELL, Henbt St. George, M.B. Edin., High street, 
Safiron Walden. 

1866* Boulton, Percy, M.D., Physician to the Samaritan Free 
Hospital ; 6, Seymour street, Portman square, W. 
Council, 1878-80, 1885. Hon. Lib. 1886. Hon. See. 
1886-9. Fice-Pree. 1890-2. Board Exam. Midwives, 
1890-1. Editor, 1894-5. ^ Trans. 4. 

1886t BousTEAD, Robinson, M.D., B.C. Cantab., Surgeon-Major, 
Indian Army; c/o Messrs. H. S. King and Co., 45, 
Pall Mall, S.W. 

1877 BowKETT, Thomas Edward, 145, East India road, Poplar, 
E. Council, 1890. 

1884* BoxALL, Robert, M.D.Cantab., Assistant Obstetric Physi- 
cian to, and Lecturer on Practical Midwifery at, the 
Middlesex Hospital ; 29, Weymouth street, Portland 
place, W. Council, 1888-90, 1894-5. Board Exam. 
Midwivea, 1891-3. Trans. 11. 
VOL. XXXVI. ( 



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XVlll FELLOWS OF THE SOCIETY. 

Elected 

1884t Boys, Aethub Heney, L.R.C.P. Ed., Chequer Lawii, St. 
Albans. 

1894 Beabant, Robeet Heebeet W. Hugees, L.R.G.P.Lond., 
137, High road, Lee, S.E. 

1886t Beadbuey, Haeyet K., 208, Ashby road, Borton-on- 
Trent. 

1894t Beadfoed, Andeew, M.D., CM., Toronto, Lanark, 
Ontario, Canada. 

I877t Beadlet, Michael Mc Williams, M.B,, Jarrow-on-Tyne. 

1873f Beaithwaite, James, M.D., Obstetric Physician to the 
Leeds General Infirmary ; Lecturer on . Diseases of 
Women and Children at the Leeds School of Medicine ; 
] 6, Clarendon road, Leeds. Fiee-Pres, 1 877-9. Trans. 6 . 
Hon, Loe, See. 

1880t Beanfoot, Aethue Mudoe, M.B., Superintendent of the 
Government Lying-in Hospital, Madras, and Professor 
of Midwifery and Diseases of Women and Children in 
the Madras Medical College, Pantheon road, Madras. . 
Hon. Loe. See. 

1887 Beidoee, Adolfhus Edwaed, M.D.Ed., 18, Portland 
place, W. 

1888*tBAiGOs, Heney, M.B., F.R.C.S., Surgeon to the Hospital 
for Women, and Hop. Med. Officer to the Lying-in 
Hospital, Liverpool ; 3, Rodney street, Liverpool. 

1864 Beight, John Meabuen, M.D., Alvaston, Park hill, Forest 
hill, S.E. Couneil, 1873-4. 

1 894 Beinton, Eoland Danyees, B.A., M.D.Cantab., 8, Queen's 
Gate terrace, S.W. 

1869 Beisbane, James, M.D., 16, St. John's Wood road, N.W. 

1885t Beiscob, John Feedeeiok, Westbrooke House, Alton, 
Hants. 

1887t Beodib, FeedeeickCaeden, M.B., Fernhill park, Wootton 
bridge. Isle of Wight. 



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FELLOWS OF THE 80CIBTT. XIX 

Elected 

1866 Bbodie, Oeoboe B., M.D., Consulting PhyBician-Accoucheur 
to Queen Charlotte's Lying-in Hospital ; 3, Chesterfield 
street, Mayfair, W. Counct/, 1873-5. Ttce-Pr^^., 1889. 

1892 Bbodie, William Haig, M.D., C.M.Edin., 88, Oxford 
terrace, Hyde park, W. 

1889t Brook, William Henry B., M.D. Lond., F.R.C.S., James 
street, Lincoln. 

1876 Brookhousb, Charles Turing, M.D., 43, Manor road, 
Brockley, S.E. 

1889t Brown, Alfred, M.A., M.D., CM. Aber., Claremont, Higher 
Broughton, Manchester. 

1868 Brown, Andrew, M.D. St. And., 1, Bartholomew road, 
Kentish town, N.W. Council, 1898-4. Trans. 1. 

1894 Brown, David, M.D.Lond., London Hospital, E. 

1865* Brown, D. Dyce, M.D., 29, Seymour street, Portman 
square, W. 

1889*tBROWN, William Carnegie, M.D. Aber., Penang, China. 

1876 Brunjes, Martin, 33a, Gloucester place, Portman square, 
W. 

1883 BuKSH, Kaheem,' The Hall, Plaistow, E. 

1885*tBuNNY, J. Brice, L.R.C.P. Ed., Newbury. 

1877t BuRD, Edward, M.D., M.C., Senior Physician to the Salop 
Infirmary; Newport House, Shrewsbury. Council, 
1886-7. Hon. Loc. Sec. 

1891 Burgess, Edward Arthur, 26, Chichele road, Crickle- 
wood, N.W. 

1894 Burt, Egbert Francis, M.B., C.M.Edin., 124, Stroud 
Green road, N. 

1888 Burton, Herbert Campbell, L.R.C.P. Lond., Lee Park 
Lodge, Blsckheath, S.E. 

1878 Butleb-Smythe, Albert Charles, L.R.C.P.Ed., 76, Brook 
street, Oros?enor square, W. Council, 1889-91. 



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XX FELLOWS OP THE SOCIETY. 

Elected 

1887* Buxton, Dudley W., M.D. Lond., 82, Mortimer street. 
Cavendish square, W. 

1886t Bybbs, John W., M.D., Professor of Midwifery and Diseases 
of Women and Children at Queen's College, and Physi- 
cian for Diseases of Women to the Royal Hospital, 
Belfast ; Lower crescent, Belfast. 

1891 Calthbop, Lionel C. Eyebabd, M.B. Durh., II, Beau- 

mont crescent. West Kensington, W. 

1887t Camebon, James Chalhebs, M.D., Professor of Midwifery 
and Diseases of Infancy, McGill University; 941, Dor- 
chester street, Montreal. 

1887t Camebon, Mubdooh, M.D.61as., Regius Professor of Mid- 
wifery in the University of Glasgow, 7, Newton terrace, 
Charing Cross, G-lasgow. 

1894t Campbell, John, M.A., M.D.Dubl., F.R.C.S., 21, Great 
Victoria street, Belfast. 

1892 Campbell, John William, B.A., M.B., B.Ch.Cantab., 

Highclere, Oakleigh park. Whetstone, N. 
1888*tCAMPBELL, William Magpie, M.D. Edin., 1, Princes gate 
East, Liverpool. 

1886t Cabpenteb, Abthub Bbistowe, M.A., M.B. Oxon., Wyke- 
ham House, Bedford park, Croydon. 

1872 Cabteb, Chables Henby, M.D., Physician to the Hospital 
for Women, Soho square ; 45, Great Cumherland place, 
Hyde park, W. Council, 1880-2. Trans. 4. 

1890 Cabteb, Robebt James, M.B.Lond., 57, Acacia road, N.W. 

1877 Cabyeb, Eustace John, 62, Sandringham road, Dalston, 
N.E. 

1887 Case, William, 34, Westboume road, Arundel square, N. 

1863t Cayzbb, Thomas, Mayfield, 9, Aigburth road, Liverpool. 

1875t Chappebs, Edwabd, F.R.C.S., Broomfield, Keighley, York- 
shire. 

1894 Chalveoott, John Henby, L.B.C.P.Lond., 401, Old 
Kent roady S.B. 



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FELLOWS OF THE SOCIETY. XXI 

Elected 

1876* Champneys, Feancis Henbt, M.A., M.D. Oxon., F.E.C.P., 
Physician-Accoucheur to, and Lecturer on Midwifery 
aty St. Bartholomew's Hospital; 42, Upper Brook 
street, W. CownctY, 1880-1. fTon. Lt6. 1882-3. Bon. 
See. 1884-7. Viee^Fref. 1888-90. Board Exam. Mid- 
wives, 1883, 1888-90; Chairman, 1891-4. Editor, 
1888-93. Free. 1895. Trane. 16. 

1859 Chance, Edwabd John, F.R.C.S., Surgeon to the Metro- 
politan Free Hospital and City Orthopaedic Hospital ; 
14, Sussell square, W.C. 

1867»tCHAELE8, T. Edmondstounb, M.D., F.R.C.P., 72, Via di 
San Niccol6 da Tolentino, Rome. Council, 1882-4. 

1874*tCHARLESWOETH, Jameb, M.D., Physician to the North 
Staffordshire Infirmary ; 25, Birch terrace, Hanley, 
Staffordshire. 

1886t Chabpentiee, Ambeose E. L., M.D.Durh., Rathmines 
House, Uxhridge. 

1892t Chepmell, Chaeles William James, M.D. Brux., 87, 

Buckingham road, Brighton. 
1868*tCHiLD, Edwin, "Vernham," New Maiden, Kingston-on- 

Thames, Surrey. 

1890t Childe, Chaeles Plumlet, B.A., F.R.C.S., Cranleigh, 
Kent road, Southsea. 

1883t Childs, Cheistophee, M.A., M.D.Oxon., Pendeen, Wey- 
mouth. Hon. Loc, Sec, 

1863*tCHi8HOLM, Edwin, M.D., Abergeldie, Ashfield, near Sydney, 
New South Wales. [Per Messrs. Turner and Hen- 
derson, care of Messrs. W. Dawson, 121, Cannon 
street, E.C.] 

1883 Clapham, Edwaed, M.D., 29, Lingfield road, Wimbledon. 
Council, 1892-4. 

1859 Claeemont, Claude Claeke, Millbrook House, 1, Hamp- 
stead ruad, N.W. 

1879 Claeke, Reginald, South Lodge, Lee park, Lee, S.E. 

1893 Claeke, W. Beuoe, F.R.C.S., 46, Harley street, W. 



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XXli FBLLOW8 OF THE 80CIBTT, 

Elected 

1876t Clay, Georm Lanospoed, West View, 443, Moseley 
road, Highgate, Birmingham. 

1889 Clemow, Arthue Henry Weiss, M.D., CM. Edin., 101, 

Earl's Court road, Kensington, W. 
O.F. Cleveland, William Frederick, M.D., Stuart villa, 

199, Maida vale, W. Council, 1863-4. Fiee-Pres. 

1875-7, 1887-9. Trans. 1. 

188lt Close, James Alex., M.B., 2031, Olive street, St. Louis, 

Missouri, U.S.A. 
1865*tCoATEs, Charles, M.D., Physician to the Bath General 

and Royal United Hospitals ; 10, Circus, Bath. 

1882t CoATES, Frederick William, M.D. (travelling). Cauneil^ 
1891-3. 

1875 Coffin, Eichard Jas. Maitland, F.E.C.P. Ed., 98, Earl's 
Court road, W. 

1878 Coffin, Thomas Walker, 22, Upper Park road, Haver- 
stock hill, N.W. 

1875*tCoLE, Richard Beverly, M.D. Jefferson Coll. Philad., 
218, Post street, San Francisco, California, U.S. 

1888t Collins, Edward Tsnison, 12, Windsor place, Cardiff. 
1877 CoLMAN, Walter Tawell (travelling). 
1866t Coombs, James, M.D., Bedford. 

1888 Cooper, Peter, L.R.C.P.Lond., Stainton Lodge, 35, 
Shooter's Hill road, Blackheath, S.E. 

1890 Copeland, William Henry Laurence, M.B.Cantah., 59» 
Warwick road. Earl's Court, S.W. 

1888t Corby, Henry, B.A., M.D., 19, St. Patrick's place, Cork. 

1875*i<'oRDE8, Aug., M.D., M.R.C.P., Consulting Accoucheur to 
the *' Mis^ricorde ;" Privat Decent for Midwifery at the 
University of Geneva ; 1 2, Rue Bellot, Geneva. Trane. 1. 

1883 Corner, Cursham, 113, Mile End road, E. 

1888t Cornish, Charles Newton, L.R.C.P. Ed., 4, Southwick 
place, Hyde park, W. 



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FELLOWS OF THE SOCIETY. XXUl 

Elected 

1860*tCoBBT, Thoha.8 Charles Steuabt, M.D., Senior Surgeon 
to the Belfast General Dispensary ; i» Glenfield place, 
Ormeau road, Belfast. Council, 1867. Fice-Prea, 
1891-3. Son. Loc. Sec. 

1888t CoBT, Isaac Rising, L.R.C.P. Lond., Shere, Guildford. 

1875 CoBT, RoBEBT, M.D., Assistant Obstetric Physician to St. 

Thomas's Hospital; 73, Lambeth Palace road, S.E. 

Coiinct/, 1879-81, 1884-5. Fice-Pree. \8S7'S8. Trana.l. 
l8S6f Cox, Joshua John, M.D. Ed., St. Eonan's, Clarendon road, 

Eccles, Manchester. 

1869t Cox, RiOHABD, M.D. St. And., Theale, near Reading. 
Trans, 1. 

,1893t Cbaio, James, M.D. Edin., Brisgow House, Beckenham. 

1877 Cbawfobd, James, M.D. Durh., Grosvenor Mansions, 80, 

Victoria street, S.W. 
188 If Cbeasy, James Gideon, West House, Wrotham, Kent 

1876t Cbew, John, Manor House, Higham Ferrers, Northampton- 
shire. 

1893 Cbipps, William Habbison, F.B.C.S., 2, Stratford 
place, W. 

1889t Cboft, Edwabd Octavius, L.R.C.P. Lond,, 8, Clarendon 
road, Leeds. 

1881t Cbonk, Hebbebt Geobge, M.B. Cantab., Eepton, near 

Burton-on-Trent. 
1893 Cbosby, Hebbebt Thomas, M.A., M.B., B.C.Cantab., 19, 

Gordon square, W.C. 

1886*tCBOS8, William Joseph, M.B., Horsham, Victoria, Aus- 
tralia. 

I889t Cbouch, Edwabd Thomas, Stoke House, Gosport. 

1875* Cullingwobth, Chables James, M.D., D.C.L., F.R.C.P., 
Obstetric Physician to, and Lecturer on Obstetric 
Medicine at, St. Thomas's Hospital; 46, Brook street, 
Grosvenor square, W. Council, 1883-5, 1891-3. 
Fice-Pres. 1886-8. Board Exam. Midwivetf 1889-91. 
Chairman, 1895. Trans. 12. 



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XXIV ( FELLOWS OF THE SOCIETY. 

Sleeted 

1889<^UB8£TJi, JehInoib J., M.D.Brux., 94, Chandanw&di, 
Bombay. 

1894 CuTLEB, Lennaed, L.B.C.P.Lond., 8, G-loucester road, 
S.W. 

1885 Dakin, William Sadfobd« M.D., Obstetric Physician to, 
and Lecturer on Midwifery at, St. George's Hospital ; 
57« Welbeck street. Cavendish square, W. Councilf 
1889-91. Hon. Lib. 1892-3. Hon. See. 1894-5. 
Trans. 3. 

1868 Daly, Fbedebiok Henby, M.D., 185, Amhurst road, 
Hackney Downs, N.E. Couneil, 1877-9. Fiee-Pres. 
1883-5. Tram. 2. 

1882t Dahbbill-Davies, William R., Alderley Edge, Cheshire. 

1893 Daubeb, John Hekey, M.A. Oxon., L.B.C.P. Lond., 29, 
Charles street, Berkeley square, W. 

1889 Davies, Feedebick Henby, M.B., C.M.Edin., 40, St. 
Stephen's avenue. Shepherd's Bush, W. 

1876 Davies, Oomeb. L.R.C.P. Ed., 9, Pembridge villas. Bays- 

water, W. 

\884 Davies, John, 91, New North road, N. 

1885 Davies, William Morbiston, M.D., 55, Gordon square, 
W.C. 

1892t Davis, Rob bet, Oakleigh, Epsom. 

1877 Davson, Smith Houston, M.D., Campden villa, 203, Maida 

vale, W. Council, 1889-91. 

1891 Dawson, Ebnest, L.R.C.P.Lond., Linden House, High 
road, Ley ton, E. 

1889t Dawson, William Edwabd, L.R.C.P.L, Walton-on-Naze, 
near Colchester. 

1859 Day, Willlim Henby, M.D., Physician to the Samaritan 
Free Hospital for Women and Children; 10, Man- 
chester square, W. Couneil, 1 873-5 . Viee-Pres. 1 885-6. 

1889 Des Yceux, Habold A., M.D.Brux., 4, Ashley gardens, 
Victoria street, S.W. 



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FBLLOW8 OF THE SOCIETY. XXY 

Elected 

1894 Dickinson^ Thomas Vincent, M.D. Lond., 33, Sloane 
street, S.W. 

1894 Dickinson, William Gilbekt, L.B.C.F. Lend., Thanet 
Lodge, Southfields, Wandsworth, S.W. 

1894 Dickson John William, B.A., M.B., B.C. Cantab., 3, 
Hertford street, W. 

1879t DoLAN, Thomas Michael, M.D., Horton house, Halifax. 

1886t Donald, Abchibald, M.A., M.D. Edin., 274, Oxford road, 
Manchester. Oouneil^ 1893-5. Trans. 1. 

1879* DoBAN, Alban H. G., F.R.C.S., Surgeon to the Samaritan 
Free Hospital ; 9, Oranville place, Fortman square, W. 
Council, 1883-5. Hon. Lib, 1886-7. Hon. See. 1888-91. 
Fice-Pree. 1892-4. Trans. 13. 

1890t DouTT, Edwabd Henbt, M.A., M.B., B.C.Cantah., 69, 
Bridge street, Cambridge. 

1887 DOYASTON, MiLWABD EdMUND. 

1893 Dowding, Alexandeb William Woodman, M.D.Durh., 
Forest Lodge, Waustead, N.E. 

1884t Doyle, E. A. Oatnes, L.R.C.P., Colonial Hospital, 
Port of Spain, Trinidad. 

O.F.f Dbaoe, Cuables, M.D., Hatfield, Herts. Council, 1861-4, 
Trans. 1. 

]885t Dbaoe, Loyell, M.A., M.D., B.S. (Oxon.)> Burleigh Mead, 
Hatfield. Council, 1894-5. 

1871t Dbakb-Bbookman, Ebwabd Fobsteb, F.R.C S., L.R.C.P. 
Lond., Brigade-Surgeon ; Superintendent Eye Infirmary, 
Madras ; Professor of Physiology and Ophthalmology, 
Madras Medical College. [Per Messrs. Richardson 
and Co., East India Army Agency, 25, Suffolk street, 
PaU MaU, S.W.] 

1884 Dbake, Chables Henbt, 204, Brixton hill, S.W. 

1894t Pbew, Henbt William, F.B.C.S., Meahurn, Coomhe 
road, Croydon. 



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XXVI FELLOWS OF THE SOCIETY. 

Elected 

1883 Duncan, Alexandeb Oeoboe, M.B., 25, Amhorst park, 
Stamford hill, N. 

O.F. DuNOAN« Jambs, M.B., 8. HeDrietta street, Govent garden, 
W.C. Council, 1873-4. Vice-Prea. 1895. 

1882 Duncan, William, M.D., Obstetric Physician to, and Lec- 
turer on Obstetric Medicine at, the Middlesex Hospital ; 
6, Harley street, W. Council, 1885-6, 1888-9. Ron, 
Lib. 1890-1. Hon, Sec. 1892-5. Trans. 2. 

1893t Dunn, Philip Henby, L.E.C.P. Lond., Stevenage, Herts. 

1871 Bastes, Geobge, M.B., F.R.C.S., 35, Gloucester place, 
Hyde park, W. Council, 1878-80. 

.I883t BccLES, F. RicHABD, M.D., Professor of Gynsecology, 
Western University ; 1, £11 wood place. Queen's avenue, 
London, Ontario, Canada. 

1892 EccLES, William McAdam, M.B.j B.S.Lond., 10, Welbeck 

street. Cavendish square, W. 

1893 Eden, Thomas Watts, M.D., C.M.Edin., 21, Bentinck 

street, Cavendish square, W. 

1890t Ehbmann, Albebt, L.R.C.P.Lond., Bitterne, near South- 
ampton. 

1879t Eldeb, Geoboe, M.D., CM., Surgeon to the Samaritan 
Hospital for Women, Nottingham; 17, Regent street, 
Nottingham. 

1878t Elleby, Richabd, L.R.C.P.Ed., Plympton, Devon. 

1894 Ellis, Eobebt Kingdon, M.B., B.Ch. Oxon., 47» Granville 

road, Stroud Green, N. 

1873*tENGELMANN, Georgb Julius, A.M., M.D., 3003, Locust 
street, St. Louis, Missouri, U.S. 

1892t Evans, John Morgan, L.R.C.P.Lond., Llandrindod Wells, 
Radnorshire. 

1875t EwABT, John Henrt, Eastney, Devonshire place, East- 
bourne. 

1894 Faibweatheb, David, M.A., M.B., C.M.Edin., 2, Nightin- 
gale road. Wood Green, N. 



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FELLOWS OF THE SOCIETY. XXYU 

Elected 

1876t Farncombe, Richard, 40, Belgrave street, Balsall heath, 
Birmingham. 

1869 Farquhab, William, M.D., Deputy Surgeon-General, 
17, St. Stephen's road, Bayswater, W. 

1861 Fabr, Geo. F., L.R.C.P. Ed., Slade House, 175, Ken- 
nington road, S.E. Council, 1885. 

1882t Farrar, Joseph, M.D., Gkiinsborough. Trana. 1. 

1894t Fazan, Charles Herbert, L.R.C.P. Lond., Belmont, 
Wadhurst, Sussex. 

1868* Fegan, Richard, M.D., Westcombe park, Blackheath, S.E. 

1886 Fennell, David, L.K.aC.P.L, 20, Dalston lane, N.E. 

1883 Fenton, Hugh, M.D., 27, George street, Hanover square, 

W. 

1893 Ferguson, George Gunnis, M.B., C.M.Glas., 62, Holm- 
dale road. West Hampstead, N.W. 

1893t FiNLET, Harry, M.D.Lond., Cumberland Infirmary^ 
Carlisle. 

1892t Finny, W. Evelyn St. Lawrence, M.B. Dubl., Kenlis, 
Queen's road, Kingston hill. 

1886t Fisher, Frederick Bazley, L.R.C.P. Lond., West Walk 
House, Dorchester. 

1882t Fitzgerald, Charles Egerton, M.D., West terrace, 
Folkestone. 

1877*tFoNMARTiN, Henry de, M.D., 26, Newberry terrace, 
Lower Bullar street, Nichols Town, Southampton. 

1884t Ford, Alexander, L.R.C.P. Ed., 9, Beresford street. Water- 
ford. 

1877*tFoRD, James, M.D., Sandford, Crediton, Devon. 

1884 FouRACRE, Robert Perriman, 20, Tollington park, N. 
1886t Fowler, Charles Owen, M.D., Cotford House, Thornton 

heath. 

l875*tf»A8ER, Angus, M.D., Physician and Lecturer on Clinical 
Medicine to the Aberdeen Royal Infirmary ; 232, Union 
street, Aberdeen. 



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XXVIU FELLOWS OF THE SOCIETY. 

Elected 

1888t Fbaseb, James Alexander^ L.R.C.P. Lond., Western 

Lodge, Romford. 
1867t Fbeeman, Henby W., 24, Circus, Bath. Council^ 1891-3. 

1883 Fuller, Henry Roxburgh, M.D. Cantab., 45, Corzon 
street. May fair, W. Couneil, 1893. Trans. 1. 

1886t Furner, Willoughby, F.R.C.S., 13, Brunswick square, 
Brighton. Council^ 1894-5. Hon. Loe. See. 

1874* Galabin, Alfbed Lewis, M.A., M.D., F.R.C.P., Obstetric 
Physician to, and Lecturer on Midwifery at, Guy's 
Hospital ; 49, Wimpole street, Cavendish square, W. 
Councily 1876-8. Hon. Lib. 1879. Hon. See. 1880-3. 
Viee^Pres. 1884. S^eas. 1885-8. Free. 1889-90. 
Trans. 12. 

1888 Galloway, Abthub Wilton, L.E.C.P. Lond., 79, New 
North road, N. 

1863* Galton, JohnH., M.D., Chunam, Sylvan road. Upper Nor- 
wood, S.E. CounctY, 1874-6, 1891-2. Fiee-Pree. 1895. 

1881 Gandy, William, Hill Top, Central hill, Norwood, S.E. 

1886t Gabde, Henby Cbokeb, F.R.C.S. Edin., Maryborough, 
Queensland. 

1887 Gabdineb, Bbuce H. J., L.R.C.P. Ed., Gloucester House, 
Barry road. East Dulwich, S.E. 

1894 Gabdneb, H. Bellamy, M.R.C.S., L.E.C.P. Lond., Chelsea 
Hospital for Women. 

1879t Gabdneb, John Twiname, Northfield House, Ilfracomhe. 

1872t Gabdneb, William, M.A., M.D., Professor of Gynaecology, 
McGill University; Gynsecologist to the Montreal 
General Hospital; 109, Union avenue, Montreal, Canada. 

1892t Gabdneb, William, M.B., C.M.Glas., 5, Collins street, 

Melbourne. 
I876t Gabneb, John, 52, New Hall street, Birmingham. 
I891t Gabbett, Abthub Edwabd, L.R.C.S., & L.M.Ed., The 

Limes, Rickmansworth. 

1873*t^ABTON, William, M.D., F.R.C.S., Inglewood, Aughton, 
near Ormskirk. 



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FELLOWS OF THE SOCIETY. XXIX 

Elected 

1889* Gbll^ Henbt Willinohah, M.A., M.B.Oxon., 43, Albion 

street, Hyde park, W. 
1859* Gebyis, Henry, M.D., F.R.C.P., Consulting Obstetric 

Pbysician to St. Tbomas's Hospital ; 40, Harley street, 

Cavendisb square. Council, 1864-6, 1889-91, 1898. 

Son. Sec. 1867-70. Vice-Free. 1871-3. Treae. 

1878-81. Free. 1883-4. Trane. 8. 
1866* Gebtis, Fbedebick Heudbboubck, 1, Fellows road, 

Haverstock hill, N.W. Council, 1877-9. Fice-Pree. 

1892. J^ane, 1. 
1884t 6ibb, Ghables John, M.D., Westgate House, Newcastle- 

on-Tyne. 
1875 Gibbings, Alpbed Thomas, M.D., 93, Richmond road, 

Dalston, N.E. Council, 1885-6, 1888. 
1883 Gibbons, Bobebt Alexandeb, M.D., Physician to the 

Grosvenor Hospital for Women and Children; 29, 

Cadogan place, S.W. Council, 1889-90. Trans. 1. 
1894 Gibson, Hbnby Wilkes, L.R.C.P. Lond., 11, College 

crescent, South Hampstead, N.W. 
1874t Gibson, James Edwabd, Hillside, West Cowes, Isle of 

Wight. 
1892 Giles, Abthub Edwabd, M.D. Lond.,M.R.C.P., Physician 

to Out-patients, Chelsea Hospital for Women ; 57, 

Queen Anne street, Cavendish square, W. Trans. 4. 
1869 Gill, William, L.B.C.P. Lond., 11, Russell square, W.C. 
1891 Gimblett, William Henby, L.R.C.P.I., 34, Pemhury road, 

Clapton, N.E. 
1891t Gledden, Alfbed Maitland, M.D., c/o L. Bruck, 13, 

Castlereagh street, Sydney, N.S.W. 
1894t GoDDABD, Chables Ebnest, L.B.C.P. Lond., Wemhley, 

Harrow. 
1871 GoDDABD, EuoENE, M.D. Durh., North Lynne, 106, High- 

hury New Park, N. Trane. 1. 
1871 ♦Godson, Clement, M.D., CM. ; 9, Grosvenor street, W. 

Council, 1876-7. Hon. Sec. 1878-81. Vtce-Pree. 

1882-4. Board Exam. Midwivee, \877» 1882-86. 

Trane. 5. 



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XXX FELLOWS OF THE SOCIETY. 

Elected 

1893t Goodman, Roger Neville, M.A., M.B.Cantab., Elmside, 
Kingston-on-Thames. 

1893t Gordon, Frederick William, L.R.G.P.Lond., Newmarket, 
Auckland, New Zealand; c/o G. Gordon, 18, Bread 
street, E.G. 

1883 Gordon, John, M.D., 20, Wickham road, Brockley, S.E. 

1869t Goss, Tregenna Biddulfh, 1, TLe Circus, Bath. Eon. 
Loe, See, 

1891t GosTLiNG, William Ayton,M.D., B.S.Lond., Barningham, 
West Worthing. 

1889 GouLLET, Charles Arthur, L.R.G.P.Lond., 2, Finchley 

road, N.W. 

1890 Gow, William John, M.D.Lond., Physician-Accoucheur 

in charge of Out-patients, St. Mary's Hospital; 27, 
Weymouth street, W. Council, 1893-5. Trans. 2. 
1893t GowAN, Bowie Campbell, L.R.G.P.Lond., Raven Dene, 
Great Stanmore. 

1893 Grant, Leonard, M.D.Edin., 9, Western villas. New 
Southgate, N. 

1890t Gray, Harry St. Clair, M.D. Gias., 15, Newton terrace, 
Glasgow. 

1875t Gray, James, M.D., 15, Newton terrace, Glasgow. 

1890 Green, Charles David, M.D.Lond., Addison House, 
Upper Edmonton. 

1894t Green, Charles Robert Mortimer, The Eden Hospital, 
Calcutta. 

1887 Greenwood, Edwin Climson, L.R.C.P., 19, St. John's 
wood park, N.W. 

1863 *Q-rifpith, G. de Gorrequer, 34, St. George's square, 

S.W. Trans. 2. 
1879* Griffith, Walter Spencer Anderson, M.D. Cantab., 

F.R.G.S., F.R.C.P., Assistant Physician-Accoucheur 

to St. Bartholomew's Hospital; 114, Harley street, W. 

Council, 1886-8, 1893-5. Board Exam. Midwives, 

1887-9. Trans. 7. 



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FELLOWS OF THE SOCIETY. XXX> 

Elected 

1870 *6bi60, William Chapman, M.D., Physician to the In- 
patients, Queen Charlotte's Lying-in Hospital; 27 y 
Curzon street, May fair. Council^ 1875-7. Board 
Exam. Midwives, 1878-9. 

1888*tGHiMSDALE, Thomas Babikgton, 6.A., M.B. Cantab., 50, 
Sodney street, Liverpool. 

1882t Gbippbb, Walteb, M.B. Cantab., The Poplars, WaUington, 

Surrey. 
1880 Gbooono, Walteb Atkins, Berwick House, Broadway, 

Stratford, E. 

I879t Gboye, William Eichabd, M.D.,St. Ives, Huntingdonshire. 
1892 Gubb, Alfbed Samuel, M.D. Paris, 29, Gower street, W.C. 
1887t Hackney, John, M.D. St. And., Oaklands, Hythe. 
1881t Haib, James, M.D., Brinklow, Coventry. 
1889 Hale, Chables D. B., M.D., 3, Sussex place, Hyde 
park, W. 

1871t Hallowes, Fbedebick B., Redhill, Seigate, Surrey. Coun- 
cil, 1885-6, 1888-90. 

1880 Hames, Geobge Henby, F.R.C.S., 29, Hertford street. 
Park lane. W. 

1894 Hamilton, Bbuce, L.R.C.P.Lond., "Falklands,"9,Frognal, 
N.W. 

1894t Hamilton, David Livingston, L.B.C.P. Edin., Great 
Misseuden, Bucks. 

1887t Hamilton, John, F.R.C.S.Ed., Beechhurst House, Swad- 
lincote, Burton-on-Treut. 

1883 Handpield-Jones, Montagu, M.D. Lond., M.R.C.P., Phy- 
sician-Accoucheur to, and Lecturer on Midwifery and 
Diseases of Women at, St. Mary's Hospital ; 35, 
Cavendish square, W. Council, 1887-9. Board 
Exam. Midwives^ 1894-5. Trans. 1. 

I889t Habdwick, Abthub, M.D. Durh., Newquay, Cornwall. 

1886t Habi>t, Henbt L. P., Holly Lodge, Richmond road, 
Kingston-on-Thames . 



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XXxii FELLOWS OP THB SOCIETY. 

Elected 

1892 Habold, John, L.R.C.P.Lond., 91, Harley street, W. 

1889 Habpbb, Chables John, L.R.C.P. Lond., Church end, 
Finchley, N. 

1877 Habpeb, Gebald S., M.B.Aber., 40, Curzon street, May- 
fair, W. CouneU, 1894-5. 

1878t Habbibs, Thomas Davies, F.R.C.S., Grosvenor House, 
Aberystwith, Cardiganshire. 

1867» Habbis, William H., M.D., 32, Cambridge gardens, W. 

1880* Habbison, Riohabd Chaelton, 19, Uxbridge road, 

Ealing, W. 
1893t Habbison, Sydney Nevill, M.B., B.C. Canteb., Aveley 

Court, Stourport. 

1890t Habt, David Bebby, M.D.Edin., 29, Charlotte square, 
Edinburgh. 

1886t Habtlby, Hobace, L.R.C.P. Ed., Stone, Staffordshire. 

1886t Habtley, Reginald, L.R.C.P. Ed., Kirkgate House, Thirsk. 

1894 Habtzhobne, Bernabd Feed., M.R.C.S., Blenheim Lodge, 
High road, Chiswick. 

1893t Habvey, John Jobdan, L.R.C.P.&S.Edin. 

1880 Habvey, John Stephenson SELWYN,M.D.Durh.,M.R.C.P., 
1, Astwood road, Cromwell road, S.W. 

1865t Habvey, Robebt, M.D., Abbottabad, Punjab. [Per 
Messrs. Cochran and Macpherson, 152, Union street, 
Aberdeen.] Trans. 1. 

1886 Habvey, Sidney Feed., L.R.C.P.Lond., 117a, Queen's 
Gate, S.W. 

1892t Hawkins- Ambleb, Geobge Abthub, F.R.C.S.Ed., 162, 
Upper Parliament street, Liverpool. 

1888t Haycock, Henby Edwabd, L.R.C.P.Bd., Ironville House, 
Alfreton, Derbyshire. 

1893t Haydon, Thomas Hobatio, M.B., B.C.Cantab., 22, High 
street, Marlborough. 



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FELLOWS OF THE SOCIETY. XXXIU 

Elected 

1873 Hayes, Thomas Cbawford, M.A., M.D., F.R.C.P., Ob- 
stetric Physician to King's College Hospital, and 
Lecturer on Practical Midwifery at King's College ; 
17, Clarges street, Piccadilly, W. Ckmneil, 1876-8. 
Vice Free, 1890-1. 

1880 Heath, William Lenton, M.D., 90, Cromwell road, 
Queen's gate, S.W. Council, 1891. Trans. 1. 

1893 Heelas, Walter Wheeler, L.R.C.P.Lond., 2» Clifton 

Terrace, Chapel Ash, Wolverhampton. 

1894 Hblby, Ernest H., L.E.C.P. Lond., Governor's House, 

H.M. Prison, Wandsworth, S.W. 

1892f Hellier, John Benjamin, M.D.Lond., Lecturer on Dis- 

eases of Women and Children, Yorkshire College; 

Surgeon to the Hospital for Women and Children, 

Leeds; 1, De Grey terrace, Leeds. 
1890t Helme, T. Arthur, M.D.Edin., 258, Oxford road, Man- 

Chester. 
186 7t Hembbough, John William, M.D., Earsdon, Newcastle- 

on-Tyne. 

1876* Herman, George Ernest, M.B., F.R.C.P., Obstetric Phy- 
sician to, and Lecturer on Midwifery at, the London 
Hospital; 20, Harley street, Cavendish square, W. 
CotinctV, 1878-9. Hon. Lib. 1880-1. Hon. See. 1882-5. 
Fiee-Pres. 1886-7. Board Exam. Midwivee, 1886-8. 
Treae. 1889-92. Free. 1893-4. Trans. 29. 

I860* Htcks, John Braxton, M.D., F.R.C.P., F.R.S., Consulting 
Obstetric Physician to Guy's and St. Mary's Hospitals ; 
34, George street, Hanover square. Council, 1861-2, 
1869. Hon. See. 1863-5. Viee-Pres. 1866-8. 
Treas. 1870. Pres, 1871-2. Trans. 40. 

1892t Hills, Thomas Hyde, L.R.C.P.Lond., 60, St. Andrew's 
street, Cambridge. * 

1886t Hodges, Herbert Chamnet, L.R.C.P.Lond., Watton, 
Herts. Trans. 1. 

O.F. Hodges, Richard, M.D., F.R.C.S., 358, Camden road, N. 
Trans. 3. 
yol. xxxyi. e 



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ZXXIV F£LLOWS OF THE SOCIETY. 

Sleeted 

1886t HoLBEBTON, Henby Nelson, L.R.C.P. Lend., East 
Molesey. 

1875 HoLLiNGS, Edwin, M.D., 25, Endsleigh gardens, N.W. 
Cauneil, 1888-90. Fiee-Free. 1893-4. 

1859 HoLMAN, CoNSTANTiNB, M.D., 26, Gloucester place. Port- 
man square, W. Council^ 1867-9, 1895. Fiee^Pree, 
1870-1. 

1891t HoLMAN, Robebt Colgatb, Whithorne House, Midhurst, 
Sussex. 

1864* Hood, Whabton Peteb, M.D., 11, Seymour street. Port- 
man square, W. 

1884 Hopkins, John, L.R.C.P. Ed., 93, Camberwell road, S.E. 

1894t HoBNE, Edwabd, M.E.C.S., St. Mary's street, Wallingford. 

1883* HoBBOCKS, Petbe, M.D., F.R.C.P. Lond., Assistant Ob- 
stetric Physician to, and Demonstrator of Practical 
Obstetrics at, Guy's Hospital ; 26, St. Thomas's street, 
S.E. Council, 1886-7. Hon. Lib. 1888-9. Hon. See. 
1890-3. Fiee^Pret. 1894-5. Trans. 2. 

1876 HoBSMAN, GoDFBEY Chables, 22, King street, Portman 

square, W. 

1893t HosKEB, James Atkinson, Kirkleatham, Boscombe, 
Bournemouth. 

1883 HosKiN, Theofhilus, L.R.C.P. Lond., 186, Amhurst road, 
N.E. 

1883 Houghin, Edmund Kino, L.R.C.P. Ed., 23, High street. 

Stepney, E. 
1884t Hough, Chables Henby, Full street, Derby. 

1877 Howell, Hobage Sydney, M.D., East Grove House, 18, 

Boundary road, St. John's Wood, N.W. 

1879t Hubbabd, Thomas Wells, Banning place, Maidstone. 

1894 Hudleston, Wilfbed E., L.R.C.P. Lond., Royal Berks 
Hospital, Reading. 

1889t HuMFHBYs, Chables Bsyeb, L.KC.P. & S. Edin., Eagle 
House, Blandford, Dorset. 



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PlfiLLOWS OF THE SOCIETY. XXXV 

Elected 

l884*tHuHRY, Jahibson Boyd, M.D. Cantab., 43, Castle street, 
Reading. Council, 1887-9. Trans. 2. 

1878t HusBAifD, Walter Edward, Ebor Lodge, Higher Brough- 
ton, Manchester. 

1894t Ilott, Herbert James, M.D. Aber., 57, High street, 
Bromley, Kent. 

1883t Inman, Robert Edward, Gadshill Cottage, Higham, Kent. 

1884t Irwin, John Arthur, M.A., M.D., 14, West Twenty-ninth 
street. New York. 

1883t Jackson, George Henry, St. Levans, Upperton, East- 
. bourne. 

1873t Jakins, William Vosfer,L.R. C.P.Ed., 165, Collins street 
East, Melbourjie. 

1872t Jalland, Robert, Horncastle, Lincolnshire. Trcau. 1. 

1890t Jambs, Charles Henry, L.R.C.P.Lond., Surg. Indian 
Army ; Lahore, India. 

1894 James, James Prytherck, L.R.C.P.I., 37, Osborne 
terrace, Clapham road, S.W. 

i885t Jamieson, Robert Alexander, M.D., Shanghai. [Per 
Messrs. Henry S. King and Co., 65, Comhill, E.C.] 

1886 Jamison, Arthur Andrew, M.D. Glas., 18, Lowndes 
street, S.W. 

1883*t Jenkins, Edward Johnstone, M.D. Oxon., 213, Macquarie 
street, Sydney. 

1877t Jbnks, Edward W., M.D., 84, Lafayette avenue, Detroit. 
Michigan, U.S. 

1882 Jennings, Charles Egerton, M.D. Durh., F.R.C.S. Eng., 
Assistant Surgeon to the North- West London Hospital ; 
48, Seymour street, Portman square, W. 

1888t Johnson, Arthur Jukes, M.B., 52, Bloor street West, 
Toronto, Ontario, Canada. 

I877t Johnson, Samuel, M.D., 5, Hill street, Stoke-upon-Trent. 

1881 Johnston, Joseph, M.D., 24, St. John's Wood park, N.W» 
Cauneil, 1891-2. 



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XXXVl FELLOWS OP THB SOCIETY. 

Elected 

1894 Johnstone, E. W., M.D., B.Ch., 36, Cheyne Coart, 
Chelsea, S.W. 

1879 Johnston, Wm. Beech, M.D., 157, Jamaica road, Ber- 
mondsey, S.E. 

1868t Jones, Eyan, Ty-Mawr, Aberdare, Glamorganshire. Couneil, 
1886-8. Viee.'Fres. 1890-1. Hon. Loc. See. 

1894 Jones, Evan, L.E.C.P. Lend., 89, Goswell road, E.C. 

1878 Jones, H. Macnauohton, M.D., F.R.C.S.I. and Edin., 
141, Harley street. Cavendish square, W. 

1881t Jones, James Robebt, M.B., 171, Donald street, Winnipeg, 
Manitoba, Canada. 

1894t Jones, John Aenallt, L.R.C.P. Lend., Heathmont, Aber- 
avon. Port Talbot, Glamorganshire. 

1887t Jones, J. Talfoubd, M.B. Lond., Consulting Physician to 
the Breconshire Infirmary, Rose Bank, South terrace^ 
Eastbourne. 

1886 Jones, Lewis, M.D., Oakmead, Balham, S.W. 

I885t Jones, P. Sydney, M.D., 16, College street, Hyde park, 
Sydney. [Per Messrs. D. Jones and Co., 122 and 124, 
Wool Exchange, Basinghall street, E.C.] 

1873t Jones, Philip W., River House, Enfield. 

1886t Jones, William Owen, The Downs, Bowdon, Manchester. 

1879t Joubert, Chables Henby, M.B. Lond., F.R.C.S. Eng., 
Snrgeon-Major, Bengal Medical Department ; Obstetric 
Physician to Eden Hospital, and Professor of Mid- 
wifery and Diseases of Women and Children, Calcutta 
Medical College ; 6, Harington street, Calcutta. 

1878t JuDsoN, Thomas Robebt, L.R.G.P. Lond., Hayman's 
Green, West Derby, Liverpool. 

1875t Jukes, Augustus, M.B., N. W, Mounted Police, Regina, 
N.-W. Territory, Canada. 

1878t Kane, Nathaniel H. E., M.D.^ Lanherne, Kingston hill, 
Surrey. 



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FELLOWS or THE SOCIETY. XXXTll 

Elected 

1890f Eanthack, Alf&bdo Antunes, M.D. Lond., St. Bar- 
tholomew's Hospital, B.C. 

1B84 Keates, William Coopsb, L.R.C.P., 2, Tredegar villas, 
East Dulwich road, S.E. 

1880t Kebbell, Alpeed, Flazton, York. 

O.F. Keelb, Geoboe Thomas, 81, St. Paul's road. High- 
bury, N. Council, 1885. 

188dt Keeling, James Hued, M.D., 267, Glossop road, Sheffield. 
Hon. Loe, Sec. 

1890 Keith, Skene, M.B., C.M.Edin., 42, Charles street, 
Berkeley Square, W. 

1894 Kellett, Alfbed Feathebstone, M.B., B.C.Cantab., 146, 
Lewisham road, S.E. 

1874* Kemfsteb, William Henby, M.D., Chesterfield, Clapham 
commou, North side, S.W. 

1886 Kennedy, Alfbed Edmund, L.R.C.P. Ed., Chesterton 
House, Plaistow, E. 

1879 Keb, Hugh Riohabd, L.R.C.P.Ed., Tintern, 2, Balham 
hill, S.W. 

1872 Kebb, Nobman S., M.D., F.L.S., 42, Grove road. Regent's 
park, N.W. 

1877*tKEB8WiLL, John Bedfobd, M.R.C.P. Ed., Fairfield, St. 
German's, Cornwall. 

1878t KuoBY, Rustonjee Nasebwanjee, M.D., M,E.C.P., 
Medical Syndic, Bombay University ; Honorary Physi- 
cian, Bai Motlibai Obstetric and Gynaecological 
Hospital ; Hormazd Villa, Khumballa hill, Bombay. 

O.F. KiALLMABK, Henby Walteb, 5, Pcmbridge gardens. Bays- 
water. Council, 1879-80. 

]892t Kingscote, Ebnest, M.B.,C.M.£din., The Hall, Salisbury. 

1892t KiNSEY-MoBGAN, AUGUSTUS, 1, Stauhopc gardens, fiourne 
mouth. 

1872* KiscH, Albebt, 186, Sutherland avenue, W. 



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XXXVlll FELLOWS OF THB SOCIETY. 

Bleated 

I876t Knott, Chaeles, M.R.C.P. Ed., Liz Ville, Elm grove^ 
Southsea. 

1889 Lake, Geoboe Robert, 72, Gloacester crescent, Hyde 
park, W. 

1867* Langfobd, Ghables P., Sunnyside, Hornsey lane, N. 

1883 Lanoley, Aaron, L.R.C.P. Ed., 149, Walworth road, S.B. 

1886 Lankester, Herbert Henry, M.D. Lend., Church Mis- 

sionary Society, Salisbury square, E.G. 
1893t Layer, Henry, Head street, Colchester. 

1887 Law, William Thomas, M.D. Edin., 9, Norfolk crescent, W. 

I875t Lawrence, Alfred Edward Aust, M.D., Physician- 
Accoucheur to the Bristol General Hospital ; 1 9. 
Richmond hill, Clifton, Bristol. Council, 1885-6, 
1888. Vice-Pres., 1889-90. Hon. Loe. See. Trans. 1. 

1894 Lea, Arnold W. W., M.D., B.S.Lond., F.E.G.S., 28, 

Cheyne row, Chelsea, S.W. 
1894t Leahy, Albebt William Denis, M.D. Durh., F.B.C.S.9 

6, Elysium road, Calcutta. 

1884*tLEDiABD, Henby Ambbose, M.D., 35, Lowther street, 
Carlisle. Council, 1890-2. Trans. 1. 

1894 Lee, Sidney Hebbebt, B.A., M.B., B.C.Cantah., Middlesex 
Hospital, W. 

1887t Lees, Edwix Lbonabd, M.D., C.M. Ed., 2, The Avenne, 
Redland road, Bristol. 

1885 Lewers, Abthub H. N., M.D. Lond., M.R.C.P., Obstetric 
Physician to the London Hospital ; 60, Wimpole street, 
W. Council, 1887-9, 1893. Board Exam. Midwives 
1895. Trans. 8. 

1877t Lewis, John Rioos Milleb, M.D. , Deputy-Surgeon General 
Markham Lodge, Liverpool road, Kingston hill, Surrey. 

1885t LiDiABD, Sydney Robebt, L.R.C.P. Ed., Berkeley House, 
Anlaby road, Hull. 

1875t LiEBMAN, Cablo, M.D. Vienna, Principal Surgeon, Trieste 
Civil Hospital, Trieste, Austria. Trans, 1. 



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FELLOWS OF THE SOCIETY. XXXIX 

Elected 

1884 LiTBBHOBE^ William Lefpinowell, L.E.C.P. Lond., 52, 
Stapleton Hall road, Stroud green, N. 

1868 Llewellyn, Evan, L.R.C.P. Ed., 114, Bethune road, Stam- 
ford hill, N. 

1872*tljoCK, John Gbiffith, M.A., 2, Rock terrace, Tenby. 

1893t Logan, Roderic Robebt Walteb, Church street, Ashby- 
de-la-Zouch. 

1859t LoMBE« Thomas Robert, M.D., Bemerton, Torquay. 

1894 Loos, William Chbistofheb, L.B.C.P. Lend., Mayfield, 
10, Hillcrest road, Sydenham, S.E. 

1890 Low, Habold, M.B.Gantab., 4, Sydney place, Onslow 
square. 

1893t Lowe, Walteb George, M.D. Loud., F.R.C.S., Burton- 
on-Trent. 

1890 Lubbook, Edgab Ashley, L.R.C.P.Lond., 4, Westfield 
terrace, Fulham road, S.W. 

1878*tLYCETT, John Allan, M.D., Gatecombe, Wolverhampton. 

1871t McCalltjm, Duncan Campbell, M.D., Emeritus Professor, 
McGill University; 45, Union avenue, Montreal, Canada. 
Trane. 4. 

1890 McCann, Fbbdebick John, M.B., G.M.Edin., M.R.C.P., 
Physician to Out-patients at the Samaritan Hos- 
pital ; 47, Welbeck street. Cavendish square, W. 
Trans. 2. 

1894t MoCausland, Albebt Stanley, M.D. Brux., Church Hill 
House, Swanage. 

1890 MoGaw, John Dysabt, F.R.C.S., Ivy House, Lincoln road. 
East Finchley, N. 

1.894t McDonnell, ^neas John, M.B. Sydney, Toowoomba, 
Queensland. 

1892t Mackay, William John, M.B., M.Ch. Sydney, 36, College 
street, Hyde Park, Sydney, N.S.W. 

1879t Macxeough, Geobge T., M.D., Chatham, Ontorio, Canada. 



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Xl FELLOWS or THB SOCIETY. 

Elected 

O.F.f Maokindeb, Drapek, M.D., ConBolting Surgeon to the 

Gamsborougb Dispensary; Gainsborough, Lincolnshire, 

OouneU, 1871-3. Trans. 2. 

1894t MoKiSAOK, Henry Lawkenoe, M.D.Dubl., 15, College 
square east, Belfast. 

1893 Macleak, Ewek Johk, M.D., CM. Edin., 51, Linden 
gardens, Kensington, W. 

1886 MoMuLLEN, William, L.K.Q.C.P.L, 319a, Brixton road, 

S.W. 

1894t McOsoAB, John, L.E.C.F. Lond., Stoneleigh, Watlington, 
Ozon. 

1893 Macphail, Abohibald Lamont, L.F.P.S. & L.M. Olas., 
138, Stoke Newington road, N. 

1884 Malcolm, John D., M.B., CM., Surgeon to the Samaritan 
Free Hospital ; 13, Portman street, W. Council, 1894-5. 

187 It Malins, Edward, M.D., Obstetric Physician to the 
General Hospital, Profeseor of Midwifery at Mason 
College, Birmingham ; 12, Old square, Birmingham. 
Council, 1881-3. Fiee^Pres, 1884-6. Hon. Loe. Sec. 

1868*tMABCH, Henry Colley, M.D., 2, West street, Roch- 
dale. Council, 1890-2. 

1887 Mabk, Leonabd P., L.R.CP. Lond., 61, Cambridge street, 

Hyde-park square, W. 

I860t Mabley, Henby Feedebick, The Nook, Padstow, ComwalL 

1862*tMARRiOTT, EoBEBT BucHANAN, SwafFham, Norfolk. 

1887t Mabsh, 0. E. Bulweb, L.R.CP. Ed., Parkdale, Clytha 
park, Newport, Monmouthshire. 

1890t Martin, Chbistopheb, M.B., C.M.Edin., 22, Broad street, 
Birmingham. Trans. 1. 

1887t Mason, Abthtjb Henby, L.R.CP.Lond., Oakwood, Walton- 
on-Thames. 

1884 Massey, Huoh Holland, 3, Peckham road, Camberwell, 
R.E. 



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FELLOWS OP THE SOCIETY. xli 

Uleeted 

1884 Habtebs, John Alfred, M.D.Durh., 57» Lezham gardens, 
Kensington, W. 

1883 Maubige, Oliyeb Galley, 75, London street, Reading. 
Cauneil, 1888-90. 

1890 May, Chichesteb Gould, M.A., M.D.Cantab., Assistant 
Physician to the Grosvenor Hospital for Women and 
Cliildren ; 26, Walton street, Pont street, S.W. 

1877 May, Lewis James, Bountis Thome, Seven Sisters road, 
Finsbury park, N. 

1884t Maynabd, Edwabd Chables, L.R.C.P.Ed., Leslie villa. 
The Vineyard, Richmond. 

189lt Mayner, Alfred Edgar, M.D.Montreal, 87, Hanover 
street, Kingston, Jamaica. 

1885t Melleb, Chables Booth, L.R.C.P. Ed., Cowbridge, Gla- 
morganshire. 

1886 Mennell, Zebulok, 1, Royal crescent, Notting hill, W. 

1882 Mebedith, William Afpleton, M.6., CM., Surgeon to 
the Samaritan Free Hospital for Women and Children ; 
21, Manchester Square, W. Council, 1886-8. Fiee- 
Pres. 1891-3. Trans. 3. 

1893 Mesquita, S. Bueno de, M.D., B.S.Lond., 1 13^ Petherton 
road, Highbury New park, N. 

1893t MiCHiE, Habby, MJB. Aber., 27, Regent street, Notting- 
ham. 

1875*tMiLES, Abijah J., M.D., Professor of Diseases of Women 
and Children in the Cincinnati College of Medicine, 
Cincinnati, Ohio, U.S. 

1876t MiLLMAN, Thomas, M.D., 490, Huron street, Toronto, 
Ontario, Canada. 

1880t Mills, Robebt James, M.B., M.C., 35, Surrey street, 
Norwich. 

1876 MiLSON, EiOHABD Henby, M.D., 88, Finchley road, South 
Hampstead, N.W. Council, 1890. 



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Xlii FELLOWS OF THE SOCIETY. 

Sleeted 

1892t Milton, Hebbert M. Nblson» Kasr-el-Aini Hospital, 
Cairo, Egypt. 

1869*tMiNN8, Pembroke R. J. B., M.D., Thetford, Norfolk. 
1867* Mitchell, Robert Nathal, M.D., 27, Fitzjohn's AYenue, 

N.W. 

1894t MoNDELET, William Henry, M.D., 1, Gladstone terrace, 
Brighton . 

1893t MoNTBBUN, D. Aktonio de, L.R.C.P. Lond., Port of Spain, 
Trinidad, W.I. 

1877 Moon, Frederick, M.B., Bezley house, Greenwich, S.E. 

1859t Moobhead, John, M.D., Surgeon to the Weymouth Infir- 
mary and Dispensary ; Weymouth, Dorset. 

1888 MoRisoN, Alexander, M.D. Ed., 14, Upper Berkeley 
street, Portman square, W. 

1890 MoRBis, Chables Abthub, M.A., M.B., B.C.Cantab., 

F.R.C.S., 29, Eccleston street, Eaton square, S.W. 
1883 MoBBis, Clabke Kelly, Gordon Lodge, Charlton road, 

Blackheath, S.E. 
1893 MoBBisoN, James, L.B.C.P. Loud., St. Bartholomew's 

Hospital, E.G. 

1893t MoBSE, Thomas Hebbebt, F.R.C.S., 10, Upper Surrey 
street, Norwich. 

1891 MoBTLOCK, Chables, L.R.C.P. Lond., 27, Oxford square, 

Hyde park, W. 

I886t Morton, Shad forth, M.D. Durham, 24, Wellesley road, 
Croydon. 

1879 Moullin, James A. Mansell, M.A., M.B., Assistant 
Physician to the Hospital for Women and Children, 
69, Wimpole street, Cavendish square, W. Trans. 1. 

1893 Muib, Robebt Douglas, L.R.C.P.Lond., 286, New Cross 
road, S.E. 

1885 Mubbay, Charles Stobmont, L.R.C.S. and L.M. Bd., 
85, Gloucester place, Portman square, W. 

1893t MuBBAT, Robebt Milne, M.B. Edin., 10, Hope street, 
Edinburgh. 



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FELLOWS OF THE SOCIETY. 



xliii 



Sleeted 

O.F. MusGKAYB, Johnson Thomas, L.E.C.P. Ed., 13, College 

terrace, BeUize park, N.W. CouneU, 1859-60. 

Trans. 1. 
1888 Myddelton-Gayet, Edward Herbert, 94, Wimpole 

street, W. 
1893t Nairnb, John Stuart, F.R.C.S. Ed., 197, Pitt street, 

... Glasgow. 
1887 Napier, A. D. Lbith, M.D. Aher.. M.R.C.P. Lend., 

F.R.S. EdiD., Physician to the Royal Maternity Charity; 

67, Grosvenor street, W. Trans. 2. 

I892t Nash, W. Gifford, F.R.C.S., 36, St. Peter's, Bedford. 

1859t Neal, James, M.D., Parterre, Sandown, Isle of Wight. 

1882t Nesham, Thomas Cargill, M.D., Lecturer on Midwifery 
in the University of Durham College of Medicine at 
Newcastle-on-Tyne ; 12, Ellison place, Newcastle-on- 
Tyne. Council, 1889-91. Fiee-Pres. 1895. 

1859*tNEWMAN, William, M.D., Surgeon to the Stamford and 
Rutland Infirmary; Barn Hill House, Stamford, 
Lincolnshire. Council, 1873-5. Fice-Pres. 1876-7. 
2^ans. 5. 

1889t Nbwnham, William Harry Christopher, M.A*, 
M.B.Cantah., 1, Leicester place, Clifton, Bristol. 

1893t NicHOL, Frank Edward, M.A., M.B., B.C.Cantah., 
11, Ethelhert Terrace, Margate. 

I873t Nicholson, Arthur, M.B. Lond., 30, Brunswick square, 
Brighton. 

1894 Nicholson, Edqar, M.B.C.S., 42, Portland road. Netting 
hiU, W. 

1879t Nicholson, Emilius Rowley, M.D., 19, Comwallis 
gardens, Hastings. 

1894 Nicoll, Thomas Verb, L.B.C.P., M.B.C.S., Sainthury, 
Upper Clapton, N.£ 

1876 Nix, Edward Jakes, M.D., 11, Weymouth street, W. 

Council, 1889-90. 
I882t Norman, John Edward, Lismore House, Hehhnm*on-Tyne. 



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Zliy PBLLOWS OF THE SOCIETY. 

Elected 

1883t NuNN, Philip W. G., L.R.C.P. Lond., Maplestead, Christ, 
church road, Bournemouth. 

1884t Oakes, Arthuk, M.D., Warialda, Portarlingtoii road, 
Bournemouth. 

1880t Oakley, John, Holly House, Ward's end, Halifax, York- 
shire. 

1894 O'Callaghan, Robert Thomas Alexander, F.B.G.S.I.y 
137, Harley street, W. 

1886 Ogle, Arthur Wesley, L.R.C.P. Lond., 90, Cannon 
street, E.C. 

O.F. Oldham, Henry, M.D., F.R.C.P., Consulting Obstetric 
Physician to 6uy*s Hospital ; 4, Cavendish place, Caven- 
dish square, W. Vice-Fres, 1859. Oauneil, 1860, 
1866-6. Trea9. 1861-2. Pres. 1863-4. Tram. 1. 
Truatee. 

1888 Oliver, Franklin Hewitt, L.R.C.P. Lond., 2, Kingsland 

road, N.E. 

1889 Oliver, James, M.D., F.R.S. Edin., F.L.8., Physician to 

the Hospital for Women, Soho square; 18, Gordon 
square, W.C. 

1884 Openshaw, Thomas Horrocks, M.B., M.S., 16, Wimpole 

street, W. 
]890t OsBURN, Harold Burgess, L.R.C.P., Bagshot, Surrey. 
1877t Ostbrloh, Paul Rudolph, M.D. Leipzic, Physician for 

Diseases of Women, Diaconissen Hospital; 16, Sido- 

uienstr., Dresden. 
1892 Owen, Samuel Walshe, L.R.C.P.Lond., 10, Shepherd's 

Bush road, W. 

1889* Page, Harry Marmaduke, M.D.Brux., F.R.C.S., 107> 
London wall, B.C. 

189 It Page, Herbert Markant, M.D.Brux., 16, Prospect hill^ 
Redditch. 

1883 Palmer, Johk Irwin, 47, Queen Anne street, Cavendish 

square, W. 
1877* Paramore, Richard, M.D., 2, Gordon square, W.C. 



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FELLOWS OF THE SOCIETY. xlv 

Elected 

1867*tPABKS, John, Bank Honse, Manchester road. Bury, Lanca- 
shire. 

1887 Pabsons, John Inglis, M.D.Durh., M.R.C.Pm Physician 
to Out Patients, Chelsea Hospi^l for Women, 3, Queen 
street, Mayfair, W. Trans, 1 . 

1880 Parsons, Sidney, 78, Kensington Park road, W. 

1889 Pabsons, Thomas Edwabd, Paddock House, Ridgeway» 

Wimbledon. 
1865*tPATEB80N, James, M.D., Hayburn Bank, Partick, Glasgow. 
1882* PsACET, William, M.D., 11, Breakspears road, Brockley, 

S.E. 
1894 Peake, Solomon, M.R.C.S., 118, Percy road, Shepherd's 

Bush, W. 
1864 Peabson, Datid Ritchie, M.D., 23, Upper Phillimore 

place, Kensington, W. Council, 1895. 
1871 Pedleb, Gsoboe Henbt, 6, Trevor terrace, Rutland gate, 

S.W. 

1880*tPBi>t'BT, Thomas Fbanklin,M.D., Rangoon, India. Trans. 1. 

1881t Pebigal, Abthub, M.D., New Baruet, Herts. Council^ 
1892-3. 

1893 Pebkins, Geoboe C. Steele, M.B., CM.Edin., 32, Wey- 

mouth street, W. 

1871t Pebbiqo, James, M.D., 53, Union avenue, Montreal, 

Canada. Hon, Loc, Sec, 
1879'^tPB8iKAKA, HoBMASJi DosABHAi, 23, Homby row, Bombay. 
1883 Pettifeb, Edmund Henbt, 32, Stoke Newington green, N. 

1894 Petty, David, M.B., C.M.,Edin., 6, High road, South 

Tottenham, N.E. 

1879 Phillips, Gsoboe Riohabd Tubneb, 28, Palace court, 

Bayswater hill, W. Council, 1891. 
1882 Phillips, John, M.A., M.D. Cantab., F.R.C.P., Assistant 

Obstetric Physician to King's College Hospital; 71, 

Grosvenor street, W. Council, 1887-9, 1893. Hon. 

24*6.1894-5. Board £»am.]lfidwives, 1892-4. Trane.S. 
189 1 Phillips, W. E. Pioton, 38, Walsingham House, Piccadilly. 



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Xlvi FELLOWS OF THE SOCIETY. 

Elected 

1878 Philfot, Joseph Henry, M.D., 61, Chester square, S.W. 
Council, 1891. 

1876 PiCAED, P. KiBKPATEiCK, M.D., 59, Abbey road, St. John's 
Wood, N.W. 

1889t PiMHOBN, Richard, L.R.C.P. Lond., 5, Cambridge terrace, 
Dover. 

1889t Playfair, David Thomson, M.D., C.M.Edin., Redwood 
House, Bromley, Kent. 

1893 Playfair, Hugh James Moon, M.D. Loud., 9, Cliveden 
place, Eaton square, S.W. 

1864* Playfair, W. S., M.D., LL.D., F.R.C.P., Physician- 
Accoucheur to H.I. & R.H. the Duchess of Edinburgh ; 
Professor of Obstetric Medicine in King's College, 
and Obstetric Physician to King's College Hospital, 
31, George street, Hanover square, W. Council, 1867. 
1883-5. Son, Librarian, 1868-9. Hon. Sec. 1870- 
72. Fiee-Pres. 1873-5. Pres, 1879-80. Trans. 15. 

1880 PococK, Frederick Ernest, M.D., The Limes,. St. Mark's 
road. Netting hill, W. 

1883 PococK, Walter, 374, Brixton road, S.W. 

1891 Pollock, William Rivers, M.B., B.C.Cantab., Assistant 
Obstetric Physician to the Westminster Hospital, 56« 
Park street, Grosvenor square, W. Council, 1895. 

1876 Pope, H. Campbell, M.D., F.R.C.S., Broomsgrove Villa, 
280, Goldhawk road. Shepherd's Bush, W. 

1891t Pope, Henry Sharland,M.B., B.C.Cantab., Castle Bailey, 
Bridgwater. 

1888 PoPHAM, Robert Brooks, L.R.C.P.Lond., 67, Bartho- 
lomew road, Camden road, N.W. 

1882t Porter, Joseph Francis, M.D., Helmsley, Yorkshire. 

1864* Potter, John Baptistb, M.D., F.R.C.P., Obstetric Physi- 
cian to, and Lecturer on Midwifery and Diseases of 
Women at, the Westminster Hospital ; 20, George 
street, Hanover square, W. Council, 1872-6, 1890-2. 
JTon. 246. 1877-8. Ftce-Prw. 1879-81. Treae. 1882-4, 
1893-5. Board Exam. Midwive9,\88S'4. Pr^. 1885-6. 
Trans. 1. 



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FELLOWS OF THE SOCIETY. Xlvii 

Elected 

1894t Pound, Clement, L.R.C.P. Lond., High street, Odiham, 
Hants. 

1893 Powell, Herbebt Edward, Glenarm House, Upper 
ClaptoD, N.E. 

1884t Powell, John James, L.R.C.P. Loud., Norwood Lodge,. 
Weybridge. 

I885t Pbaegeb, Emil Abnold, Rooms 56 — 57* Potomac Block, 
Broadway, Los Augeles, Cal. 

1886 Pbanqley, Henry John, L.R.C.P. Loud., Tudor House^ 
197, Anerley road, Anerley, S.E. 

1893t Pratt, William Sutton, M.D., Alma House, Bugby. 

1880* Pbickett, Marmaduke, M.A.Cantab., M.D., Physician to 
the Samaritan Hospital ; 27, Oxford square, W. 
Council, 1892. 

O.F.* Priestley, Sir William 0., M.D., LL.D., F.R.C.P., Con- 
salting Obstetric Physician to King's College Hos- 
pital; 17, Hertford street. May fair, W. Council, 
1859-61, 1865-6. Fice-Pres. 1867-9. Pres. 1875-6, 
Trans. 6. 

1893 Probyn- Williams, Robert James, M.D.Durh., 22, Duke 

street, Portland place. 

1876*tQuiRKK, Joseph, L.R.C.P. Ed., The Oaklands, Hunter's 
road, Handsworth, Birmingham. 

J861 Rasch, Adolphus A. F., M.D., Physician for Diseases of 
Women to the German Hospital ; 7, South street, Fins- 
bury square, E.G. Council, 1871-3. Trans. 6. 

1878t RawlingSjJohn Adams, M.R.C.P.Ed.,Preswylfa, Swansea. 

1870* Ray, Edward Reynolds, Dulwich, S.E. 

1894 Baynsr, Herbert Edward, F.E.C.S., 68, Porchester 

terrace, W. 

1860* Bayner, John, M.D., Swaledale House, Highbury quad- 
rant, N. 

1879 Read, Thomas Laurence, 11, Petersham terrace, Queen's 
gate, S.W. Council, 1892. 



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Xlviii FELLOWS OF THE SOCIETY. 

Elected 

1874 Rebs, William, Priory HouBe, 1 29, Queen's crescent. Haver- 
stock hiU, N.W. 

1879t Reid, William Loudon, M.D., Professor of Midwifery and 
Diseases of Women and Children, Anderson's College ; 
Pliysician to the Glasgow Maternity Hospital ; 7, Royal 
crescent, Glasgow. 

1889 Remfkt, Leonard, M.A., M.D., B.C. Cantab., Assistant 

Obstetric Physician to, and Assistant Lecturer on 
Obstetric Medicine at, St. George's Hospital ; 60« 
Great Cumberland place, Hyde park, W. Council, 
1894-5. Trans. 2. 

1893t Renshaw, Israel James Edward, F.R.C.S.Edin., G^rse 
Lea, Sale, near Manchester. 

1875*tSET, EuGENio, M.D., 39, Via Cavour, Turin. 

1890 Reynolds, John, M.D.Bruz., 11, Brixton hill, S.W. 

1872t Richardson, William L., M.D., A.M., Professor of Obs- 
tetrics in Harvard University ; Physician to the Boston 
Lying-in Hospital; 225, Commonwealth avenue, 
Boston, Massachusetts, U.S. 

1889t Richmond, Thomas, L.R.C.P.Ed., 2, West garden street, 
Glasgow. 

1872t RiQDEN, George, Surgeon to the Canterbury Dispensary; 
60, Burgate street, Canterbury. Tram, 1 . J9on. Loe. 
See. 

1871* RiGDEN, Walter, M.D. St. And., 16, Thurloe place, S.W, 

Council, 1882-3. Trans, 1. 
1892 Roberts, Charles Hubert, M.B.Lond., F.R.C.S. Eng., 

M.R.C.P., 21, Welbeck street. Cavendish square, W. 

O.F.*tRoBERT8, David Lloyd, M.D., F.R.C.P., F.R.S. Bdin., 
Obstetric Physician to the Manchester Royal Infirmary ; 
and Lecturer on Cliuical Midwifery and the Diseases of 
Women in Owens College ; 1 1, St. John street. Deans- 
gate, Manchester. Council, 1868-70, 1880-2. Vice- 
Pres. 1871-2. Trans. 5. 

1867* Roberts, Datid W., M.D., 56, Manchester street, Man- 
chester square, W. 



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FELLOWS OF THE SOCIETY. xlix 

Elected 

1890t Roberts, Hugh Jones, Sea View, Penygroes, R.S.O., N. 
Wales. 

1883 EoBERTS, John Coeyton, L.R.C.P. Ed., 71, Peckham 
rye, S.E. 

1893 Roberts, Thomas, 95, Tredegar road, Bow, E. 

1894 Robertson, Cecil, M.B., C.M.Aber., 12, GranYille road, 

Southfields, Wandsworth, S.W. 
1874 Robertson, William Borwick, M.D., St. Anne's, Thurlow 
park road. West Dulwich, S.E. 

1892 Robinson, George H. Drummond, M.D., B.S. Lond., 
84, Park street, Grosvenor square, W. 

1887 Robinson, Hugh Shapter, L.R.C.P. Ed., Talfourd House, 
Camberwell, S.E. 

1884t Robinson, Luke, M.R.C.P. Lond., 533, Sutter street, San 
Francisco, California. 

1892 Robinson, Mark, L.R.C.P. Lond., Geraldine Lodge, 
75, East hill, Wandsworth, S.W. 

1890t RoBSON, A. W. Mato, F.R.C.S., 7, Park square, Leeds. 

1876t Roe, John Withington, M.D., EUesmere, Salop. 

1874t Roots, William Henry, Canbury House, Kingston-on- 
Thames. 

1874 Roper, Arthur, M.D.St.And., Colby, Lewisham hill, S.E. 
Council, 1886-8. 

1865*tRoPEB, George, M.D., Consulting Physician to the Royal 
Maternity Charity ; Oulton Lodge, Aylsham, Norfolk. 
Ckmndly 1875-7, 1883-5. Fice-Pres. 1879-81, 1889, 
Board Exam. Midwives, 1880-1, 1883-5. Trans. 10. 

1859 Boss, Henry Cooper, M.D., Penrose House, Hampstead, 
N.W. Council, 1875-7. Trans. 4. 

1893t RosENAU, Albert, M.D., H6tel Victoria, Kissingen, 
Bavaria . 

1884t RossiTEB, George Frederick, M.B., Surgeon to the 
Weston-super-Mare Hospital; Cairo Lodge, Weston- 
super-Mare. 

d 



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1 FELLOWS OF THB SOCIETY. 

Elected 

1884t RouGHTON, Walter, F.E.C.S., Cranborne House, New 

Barnet. 
1882 RouTH, Amand, M.D., B.S., Assistant Obstetric Physician 

to, and Teacher of Practical Obstetrics and Gynaecology 

at. Charing Cross Hospital; 14a, Manchester square, 

W. extinct/, 1886-8. Board Exam. M%dmve9,\S9Z'b. 

Trans. 3. 
O.F.* RouTH, Chables Heney Felix, M.D., Consulting Physician 

to the Samaritan Free Hospital for Women and Children ; 

52, Mon tagu square, W. Council^ 1 85 9-6 1 . Fiee-Pres. 

1874-6. Trans. 13. 

1887*tRowB, Arthur Walton, M.D. Dur., 1 , Cecil street, Margate. 

188 If RowoRTH, Alfred Thomas, Grays, Essex. 

1886 RusHWORTH, Frank, M.D. Lond., 1a, Goldhurst terrace. 
South Hampstead, N.W. 

1888t BusHWORTH, Norman, L.R.C.P. Lond., Beechfield, Walton- 

on-Thames. 
1886t RuTHERFOORD, Henry Trotter, B.A., M.6. Cantab., 

Park street, Taunton. Council, 1892-3. Trans. 1. 
1866*tSABOiA, Baron V. de, M.D., Director of the School of Medi- 

cine, Rio de Janeiro ; 7, Rua dom Afifonso, Petropolis, 

Rio Janeiro. Trans. 2. 

1864*tSALTER, John H., D'Arcy House, Tolleshunt d'Arcy, Kel- 
vedon, Essex. Council, 1894-5. 

1868* Sams, John Sutton, St. Peter's Lodge, Eltham road, Lee, 
S.E. Council, 1892. 

1886t Sanderson, Robert, M.B. Oxon., 98, Montpellier road, 
Brighton. 

1872 Sanoster, Charles, 148, Lambeth road, S.E. 

1870t Saul, William, M.D., Lyndthorpe,Boscombe, Bournemouth. 

1891 Saunders, Frederick William, M.B., B.C.Cantab., 
Chieveley House, near Newbury. 

1872t Savage, Thomas, M.D., Surgeon to the Birmingham and 
Midland Hospital for Women ; 33, Newhall street, 
Birmingham. Council, 1878-80. 



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FELLOWS OF THE SOCIETY. li 

Elected 

1877 Sayokt, Ghakles Tozeb, M.D., 6, Douglas road. Canon- 
bury, N. Trans. 1. 

1894t Savory, Horace, M.A., M.B., B.C. Cantab., Haileybury 
College, Hertford. 

1890 ScHACHT, Frank Frederick. B.A., M.D.Cantab., 168, 

Earl's Court road, S.W. 
1870t Scott, John, M.D., Cramond House, Sandwich. 
1888 Scott, Patrick Cumin, B.A., M.B. Cantab., 38, Shooter's 

Hill road, Blackheath, S.E. 

1866 Sequeiba, James Scott, 68, Leman street, Goodman's 

fields, £., and Crescent House, Cassland crescent, 

Cassland road. South Hackney, N.E. 
1882 Serjeant, Dayid Maurice, M.D., 1, The Terrace, Cam- 

berwell, S.E. 
1875 SsTON, Dayid Elphinstone, M.D., 1, Emperor's gate, 

S.W. Council, 1884. 
1894t Sharpin, Archdale Lloyd, L.E.C.P. Lond., 2, Rimbolton 

road, Bedford. 

O.F.t Sharpin, Henry Wilson, F.R.C.S., Consulting Surgeon 
to the Bedford General Infirmary ; 1, St. Paul's square, 
Bedford. Council, 1871-3. Trans. 1. Hon. Loe. Sec. 

1887 Shaw, John, M.D. Lond., Obstetric Physician to the North 
West London Hospital ; 34, Queen Anne street. Caven- 
dish square, W. Trans, 2. 

1891 Shaw-Mackenzie, John Axexander, M.B.Lond., 24, 

Sayile row, W. 

1890 Silk, John Frederick William, M.D. Lond., 29, Wey- 
mouth street, Portland place, W. 

1874t Sinclair, Alexander Doull, M.D., Consulting Physician 
to the Boston Lying-in Hospital ; 35, Newbury street, 
Boston, Massachusetts, U.S. 

1888t SiNCLAiB, William Japp, M.D. Aber., Honorary Physician 
to the Southern Hospital for Women and Children and 
Maternity Hospital, Manchester; and Professor of 
Obstetrics and Gynaecology, Owens College, Man- 
chester ; 250, Oxford road, Manchester. 



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lii FELLOWS OF THE SOCIETY. 

Elected 

1879 Slight, Geoboe, M.D., 14» Old Burlington street, W. 

1881t Sloan, Abchibald, M.6., 272, Bath street west, Olasgow. 

1876t Sloan, Samuel, M.D., CM., 5, Somerset place, Saucbiehall 
street west, Glasgow. 

1890t Sloman, Fbedebick, 18, Montpellier road, Brighton. 

1861 Slymak, William Daniel, 26, Caversham road, Kentish 
Town, N.W. Council, 1881. 

1867* Smith, Heywood, M.D., 18, Harley street, CaYendish 
square, W. Council, 1872-5. Board Exam. Midwivea, 
1874-6. Tram. 6. 

1888t Smith, Howabd Lyon, L.R.C.P.Lond., Buckland House, 
Buckland Newton, near Dorchester. 

1894 Smith, Hugh Roubiliao, M.B.Lond., 7» Gordon street, 
Gordon square, W.G. 

1875 Smith, Eichabd Thomas, M.D., Physician to the Hospital 
for Women, Soho square ; 53, Hayerstock hill, N.W. 

I886t Smith, Samuel Pabsons, L.K.Q.C.P.I., Park Hyrst, 
Addiscombe road, Croydon. 

1882t Smith, Stephen Mabebly, L.R.C.P. Ed., Keerie Kara, 
Ryrie Street, Geelong, Melbourne. [Per Henry M. 
Smith, Ellerslie, Eltham.] 

1879t Smith, Walteb Hugh Montgomeby, L.R.C.P.Ed., 47, 
London road. West Croydon. 

1 868"^ Spaull, Babnabd E., 1, Stanwick road, West Kensington, W. 

1888'*' Spencer, Hebbebt R., M.D., B.S.Lond., Professor of Mid- 
wifery in UniYersity College, London, and Obstetric 
Physician to University College Hospital; 10, Mans- 
field street, Cavendish square, W. Council, 1890-92. 
Trans. 2. 

1876t Spenceb, Lionel Dixon, M.D., Brigade-Surgeon, LM.S., 
Bengal Establishment [care of Messrs. Grindlay and Co., 
55, Parliament street, SW.]. 

1882 Spooneb, Fbedebick Henby, M.D., Maitland Loage, 
Maitland place, Clapton, N.E. 



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FELLOWS OF THE SOCIETY. liu 

Elected 

1876t Spubgin, Hebbebt Bban white, 82, Abington street, 
Northampton. 

1893 Stack, E. H. Ebwabds, M.B., B.C. Cantab., St. Bar- 

tholomew's Hospita], E.G. 

1894t Steeb, Adam William Thobbubn, M.R.C.S., L.E.C.P. 
Eng., Trevear, Penzance. 

1894 Steyens, Thomas Oeoboe, M.D., B.S. Lond., 1, Newing- 

ton green, N. 

1884t Steyenson, Edmond Sinclaib, F.R.C.S. Ed., Strathallan 
House, Rondebosch, Cape of Good Hope. Trans, 2. 

1877t Stephenson, William, M.D., Professor of Midwifery, 
University of Aberdeen ; 3, Rubislaw terrace, Aberdeen. 
Council, 1881-3. Fice-Pres., 1887-9. Trans. 2. 

1873t Stewabt, James, M.D. 

1875*tSTBWABT, William, F.K.C.P. Ed., 26, Lethbridge road, 
Southport. 

1884t Stiyen, Edwabd W. F., M.D., The Manor Lodge, Harrow- 
on-the-Hill. 

1884 Stiybns, Bebtbam H. Lyne, M.D.Brux., 11, Kensington 
gardens square, W. 

1883 Stocks, Fbedebick, 421, Wandsworth road, S.W. 

1894t Stote, William Atkinson, M.E.C.S., L.E.C.P. Lond., 
1 , Grove terrace, Leeds. 

1866* Stbanqb, William Heath, M.D., 2, Belsize avenue, 
Belsize park, N.W. Council, 1882-4. 

1884 Sundbbland, Septimus, M.D., 35, Bruton street, Berkeley 

square, W. 

1886t SuTCLiFFE, Abthub Edwin, Chorlton Lodge, Stretford 
road, Manchester. 

1883* SuTHEBLAND, Henby, M.A., M.D. Oxon., M.R.C.P., 6, 
Eichmond terrace, Whitehall, S.W. 

1888 Sutton, John Bland, F.R.C.S., 48, Queen Anne street, 
Cavendish square, W. Council, 1894-5. Trans, 1. 



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liy FELLOWS OF THE SOCIETY. 

Elected 

1894 Swallow, Allan James, M.B., B.S. Durh., 5, Mount 
Edgecumbe gardens, Glapham rise, S.W. 

1893 Swan, Richabu Joceltn, Park House, 32, Camberwell 
new road, S.E. 

1893 S WAYNE, Francis Griffiths, M.A., M.B., B.C.Cantab., 
4, Belvedere road, Upper Norwood, S.E. 

1859*tS WAYNE, Joseph Griffiths, M.D., Physician-Accoucheur 
to the Bristol General Hospital ; Harewood House, 
74, Pembroke road, Clifton, Bristol. Council, 1860-1, 
Vice^Pres, 1862-4. Trane, 9. 

1892t Sw^AYNE, Walter Carless, M.B. Lond., 3, Leicester villas, 
St. Paul's road, Clifton. 

1888"^ Sworn, Henry Georqe, L.K.Q.C.P. & L.M., 5, Highbury 
crescent, N. 

1883 Tait, Edward Sabine, M.D., 48, Highbury park, N. 
Council 1892-4. Trans. 1. 

1879 Tait, Edward W„ 48, Highbury park, N. Council, 1886-7. 

1871*tTAiT, Lawson, F.R.C.S., Surgeon to the Birmingham and 
Midland Hospital for Women ; 7» The Crescent, Bir- 
mingham. Trans. 15. 

1880*tTAKAKi, Kanaheiro, F.R.C.S., 10, Nishi-Konyachd, Rid- 
bashika, Tokio, Japan. Hon. Loc. Sec. 

1859 Tapson, Alfred Joseph, M.B. Lond., 36, Gloucester gar- 
dens, Westbourne terrace, W. Council, 1862-4. 
Vice-Pres. 1891. 

1891 Taroett, James Henry, M.B., M.S. Lond., F.R.C.S., 6, 

St. Thomas's street, S.E. Council, 1895. 

1892 Tate, Walter William Hunt, M.B.Lond., 4, Queen 

Anne street, Cavendish square, W. Council, 1895. 

1871 Taylsr, Francis T., B.A. Lond., M.B., Claremont Yilla, 
224, Lewisham High road, S.E. 

1869t Taylor, John, Earl's Colne, Halstead, Essex. 

l890*tTAYLOR, John William, F.R.C.S., 59, Bath street, Bir- 
mingham. Tram. 1. 



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FELLOWS OF THE SOCTETY. 1y 

Bleeted 

1892 Tatlok, William Bramlet, 145, Denmack hill, S.B. 

]885t Tatlob, William Charles Etbrley, M.R.G.P. Edin., 34, 

Qneen street, Scai^borough. 
1894t Tench, Montague, M.D. Brux., L.R.G.P. Lond., Great 

Dunmow, Essex. 
1890t Thomas, Benjamin Wilfbed, L.R.G.P. Lond., Welwyn. 
1884 Thomas, George H. W. 

1887t Thomas, William Edmund, L.R.C.P.Ed., 2, Station hill, 

Bridgend, Glamorganshire. 
1882t Thomas, Hugh, The Grange, Coyentry road, Birmingham. 
] 867 *tTH0MFS0N, Joseph, L.R.G.P. Lond., 1, Oxford street, 

Nottingham. Tram. 1. Hon. Loe, See, 

1878t Thomson, David, M.D., Park square, Luton, Bedford- 
shire. 

1879 Thornton, J. Knowsley, M.B., G.M., Surgeon to the 
Samaritan Free Hospital for Women and Children, 49, 
Montagu square, W. Council, 1882-3. Hon. Lib. 
1884-6. Hon. See. 1886. Fiee-Pres. 1888, 1893. 
Trans. 6. 

1873t TicEHURST, Gharles Sage, Petersfield, Hants. 

1866 TiLLEY, Samuel, 32, West Kensington gardens, W. 

1887t TiNLEY, Thomas, M.D.Durh., Hildegard House, Whithy. 

1879t TiYY, William James, F.R.G.S. Ed., 8, Lansdown place, 

Glifton, Bristol. 
1872t ToLOTSOHiNOFF, N., M.D., Gharkoff, Russia. 
1884 Traters, William, M.D., 2, Phillimore gardens, W. 

1873t Trbstrail, Henry Ernest, F.R.G.S.Ed., M.R.GP.Ed., 
36, Westhourne gardens, Glasgow, W. Trans. 1. 

1893 Trbthowan, William, M.B., C.M.Aher., 56, Grosvenor 

street, W. 

1886 Tuckett, Walter Reginald, Woodhouse Eaves, near 
Loughborough. 

1865* Turner, John Sidney, Stanton House, 81, Anerley road, 
Upper Norwood, S.E. Council^ 1893-4. 



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Ivi FELLOWS OF THE SOCIETY. 

Elected 

1891 Turner^ Philip Dyhock, M.D.Lond.^ 95, Cromwell 

road, S.W. 
188 It TuTHiLL, Phineas Babeett, M.D.» Station HoBpital, 

Gibraltar. 
1861 Tweed, John James, jun., F.R.C.S., 14, Upper Brook 

street, W. 

1890 Tyreell, Walter, 'L.R.C.P.Lond., 104, Cromwell road, 
S.W. 

1893 Umnet, William Francis, M.D.Lond., Heatherbell, 15, 

Crystal Palace park road, Sydenham, S.E. 

1874 Venn, Albert John, M.D., Physician for the Diseases 
of Women, West London Hospital ; 70a, Grosvenor 
street, W. 

1873 Verley, Reginald Louis, F.R.C.P. Ed., 28b, Devonshire 
street, Portland place, W. 

1892t Vereall, Thomas Jenner, L.R.C.P.Lond., 97, Mont- 
pellier road, Brighton. 

1879t Wade, George Herbert, Ivy Lodge, Chislehurst, Kent. 
Council^ 1892-3. 

1894t Wagstafp, Frank Alex., L.E.C.P. Lond., The Square, 
Leighton Buzzard. 

1860t Wales, Thomas Garnets, Downham Market, Norfolk. 

1894 Walker, Thomas Alfred, L.E.C.P. Edin.,* Greville Lodge, 

Willesden park, N.W. 

I866t Walker, Thomas James, M.D., Surgeon to the General 
Infirmary, Peterborough ; 33, Westgate, Peterborough. 
Council, 1878-80. H&n. Loc. See. 

1889 Wallace, Abraham, M.D. Edin., 64, Harley street, W. 

1870 Wallace, Frederick, Foulden Lodge, Upper Clapton, 
N.E. Council, 1880-2. 

1872*tWALLACB, John, M.D., Assistant-Physician to the Liverpool 
Lying-in Hospital; 1, Gambier terrace, Liverpool. 
Oouncil, 1883-5. 

1883 Wallace, Richard Unthank, M.B., Cravenhurst, Craven 
park, Stamford hill, N. 



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FELLOWS OF THE SOCIETY. Ivil 

Elected 

1893t Walls, Willlam Kay, M.B. Lond., St. Mary's Hospital, 
Manchester. 

1879* Waltbb, William, M.A., M.D., Surgeon to St. Mary's 
Hospital, Manchester; 20, St. John street, Man- 
chester. 

1867* Waltebs, James Hopkins, Surgeon to the Royal Berkshire 
Hospital ; 15, Friar street, Reading, Berks. Council^ 
1884-6. Tran9, 1. Hon, Loc, See, 

1873t Walters, John, M.B., Church street, Reigate, Surrey. 

1894 Ward, William Alfred, L.E.C.P. Lond., Middlesex 

Hospital, W. 
1884t Watson, Peboiyal Humble, L.E.C.P. Lond., 72, Jesmond 

road, Newcastle-on-Tyne. 
1884t Waugh, Alexander, L.R.C.P. Lond., Midsomer-Norton, 

Bath. 
O.F.t Webb, Habby Speakman, New place, Welwyn, Herts. 

Oouneil, 1889-91. Fiee.-Pres. 1892-4. 
1893t Webb, James Samsay, M.B., B.S.Melbourne, 82, 

St. Vincent place south, Albert park, Melbourne. 

1894 Webb, John Curtis, B.A. Cantab., 14,Cranley place, S.W. 

1886t Webber, William W., L.R.C.P. Ed., Crewkerne. 

1893t Wbbsteb, Thomas James, Bryngl&s, Merthyr Tydvil. 

1887t Wells, Albebt Pbimrose, M.A., L.R.C.P. & S., L.M. 
16, Albemarle road, Beckenham. 

1876t Wells, Frank, M.D., 178, Devonshire street, Boston, 
Massachusetts. 

O.F. Wells, Sir T. Spencer, Bart., F.R.C.S., Surgeon in Ordi- 
nary to H.M.'s Household ; Consulting Surgeon to the 
Samaritan Free Hospital for Women and Children ; 3, 
Upper Grosvenor street, W. Council^ 1859. Vice- 
Free. 1868-70. Tram, 5. Trustee. 

1886t West, Charles J., L.R.C.P. Lond., The Grove, Fulbeck, 
Grantham. 

1888t Weston, Joseph Theophilus, M.D.Br ax., Prome, Lower 
Burmah, India. 
VOL. ZZXYI. 6 



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Iviii FBLLOWS OF THB SOCIBTY. 

Elected 

1886 Wharby, Robert^ M.D. Aber., 6, Gordon square, W.G. 

1890 Wheaton, Samuel W., M.D.Lond.^ Physician to the Royal 
Hospital for Children and Women; 52, The Chase, 
Clapham common, S.W. 

1889t Whitcombe, Cuables Henby, F.R.C.S. Bdin., 281, 
Queen's road, Halifax. 

1890 White, Chables Perciyal, M.A., M.6., fi.C.Cantab., 
144, Sloane street, S.W. 

1890 White, Edwin Fbancis, F.R.C.S., Westlands, 280, Upper 
Richmond road. Putney, S.W. 

1882 Wholey, Thomas, M.B. Durh., Winchester House, 50, Old 
Broad street, E.C. 

1877 WiGMOBE, William, 131, Inverness terrace, Hyde park, W. 

1879t WiLLANs, William Blundell, F.R.C.P. Ed., Much Had- 
ham, Herts. 

1889t Williams, Abthub Henby, M.A., M.B., B.C. Cantab., 54, 
London road, St. Leonard's-on-Sea. 

1887t Williams, Chables Robert, M.B., CM. Ed., 15, Ivanhoe 
terrace, Ashby-de-la-Zouch. 

I894t Williams, John D., M.D. Ed., B.Sc, 20, Windsor place, 
Cardiff. 

1872 Williams, Sir John, Bart., M.D., F.R.C.P., Physician- 
Accoucheur to H.R.H. Princess Beatrice, Princess 
Henry of Battenberg ; Consulting Obstetric Physician 
to University College Hospital ; 63, Brook street, Gros- 
venor square, W. Council, 1875-6, 1892, 1894. 
Hon, Sec. 1877-9. Fice-Pres. 1880-2. Board Exam. 
Midlives, 1881-2; Chairman, 1884-6. Free, 1887-8. 
Trans. 12. 

1890 Williams, Reginald Muzio, M.D.Lond., 95, St. Mark's 
road, N. Kensington, W. 

1881 Willis, Julian, M.R.C.P.Ed., 64, Sutherland ayenne, 
Maida yale, W. 



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FELLOWS OP THE SOCIETY. Ux 

Elected 

1860t Wilson, Robert Jambs, F.R.C.P. Ed., 7, Warrior square, 
St. Leonard's-OD-Sea, Sussex. Hon, Loe. See, Fiee- 
Free, 1878-80. 

1892t Wilson, Thomas, M.D., B.S.Lond., F.R.C.S., Assistant 
Obstetric Physician at the General Hospital, Birming- 
ham ; 33, Paradise street, Birmingham. 

1886t Winterbottom, Aethua Thomas, L.R.C.P. Ed., Lark hill, 
Swinton, Manchester. 

1877 WiNTLE, Henry, M.B., Kingsdown, Church road, Forest 
hm,S.E. 

1893 Wise, Robert, M.D.Edin., 5, Weston park, Crouch End, 

N. 

1887t Withers, Robert, Stenteford Lodge, Spencer terrace, 
Lipson road, Plymouth. 

1893 WooDROFPE, John FitzHenry, M.D.Dubl., 48, Mildmay 
park, N. 

1890 WoRNUM, Oeorge Porter, 6, College terrace, Belsize park, 

N.W. 

1881t Worthington, George Finch Jennings, M.K.Q.C.P., 
Thorncliffe, Poole road, Bournemouth. 

1876t Worts, Edwin, 6, Trinity street, Colchester. 

1887t Wright, Charles James, Senior Surgeon to the Hospital 
for Women and Children, Leeds; Professor of Mid- 
wifery to the Yorkshire College ; Lynton Villa, Virginia 
road, Leeds. 

1888*tWYATT. Smith, Frank, M.B., B.C.Cantab., British Hospital, 
Buenos Ayres. 

1889 Wynter, Andrew Ellis, M.D., The Corner House, 
Beckenham. 

1871 Yaerow, George Eugene, M.D., 26, Duncan terrace, 
Islington, N. Couneil, 1881-3. 

l882*tYoiJNG, Charles Grove, M.D., New Amsterdam, Berbice, 
British Guiana. 



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CONTENTS. 





PAOS 


Liflt of Officers for 1895 . . . . 


▼ 


List of Presidents 


vii 


List of Referees of Papers for 1895 


. viii 


Standing Oommittees . . . . 


iz 


List of Honorary and Corresponding Fellows 


zi, zii 


List of Ordinary Fellows 


. xiii 


Contents .... 


. Ixi 


List of Plates .... 


. Izvi 


Listof Woodonts . . . . 


. Ixvii 


Advertisement . . . . . 


.Ixviii 



January 3rd, 1894 — 

Beport of Committee on Dr. Amand Bouth's Specimen 

of Fibroma spontaneously enucleated ('Transac 

tions/ vol. zzzv, p. 409) 
Uterus from a Septic Case, shown by Dr. Charles 

Chepmbll .... 
Hypertrophied Nymphs and Clitoris, shown by Dr. 

William DuNOAN 
A Malformed Beart, shown by Dr. Pbobyn- Williams 
Hydrocephalus with Spina Bifida, shown by Dr. 

Fbobyn-Williams 
Unruptured Tubal Gestation, shown by Dr. Eden 
I. Six more Cases of Pregnancy and Labour with Bright's 

Disease. By Dr. HsBMAif 
U. A Note on Vaginal Secretion. By Dr. Gow 



2 
3 
3 

3 
3 

4 
5 



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Ixii CONTENTS. 

PAOB 

February 7th, 1894. 

Annnal Meeting . • 61 

Abscess in Abdominal Wall^ shown by Dr. Pbobtn- 

W11J.IAM8 .62 

Uterine Fibroids removed by Enucleation fifteen days 

after DeliTery, shown by Dr. Boxall . 64 

Acephalous Acardiac Foetus, shown by Dr. Herman, 

for Mr. Qrogono .65 

Tubal Gestation of nine weeks' duration successfully 

removed three hours after rupture, shown by Dr. 

William Duncan .66 
ATiTnift.1 Meeting — ^Adoption of the Laws as revised . 71 
The Audited Report of the Treasurer (Dr. 

POTTBB) . 71,72 
Report of the Honorary Librarian for 1893 (Dr. 

Dakin) . .73 
Report of the Chairman of the Board for the 

Examination of Midwives (Dr. Ghampneys) 73 

Annual Address of the President (Dr. Hebman) 75 

Election of Officers and Gouncil for the year 1894 110 

March 7th, 1894- 

Ruptured Tubal Gestation, shown by Dr. William 

Duncan . . .114 

Fibroid Polypus of Cervix, shown by Dr. William 

Duncan . . .114 

Fcetus at seven months, illustrating Oelosoma with 
Retroflexion, Meningocele, and Talipes Yarns, 
shown by Dr. Leith Napier .116 

III. A Plea for the practice of Symphysiotomy, based 
upon its record for the past eight years^ by Dr. 
Robert P. Habbib .117 

lY. On the Relation of Heart Disease to Menstruation, 

by Dr. Gow . . .126 

April 4th, 1894— 

Foetus and Placenta removed by Laparotomy, from a 

Gase of Extra-uterine Gestation, shown by Dr. 

William Duncan . .146 

Oase of Gydops, shown by Dr. Ettleb . . 149 

Hypertrophied Nymphsa and Glitoris, shown by Dr. 

William Duncan .... 149 
Report of Gommittee on the above . . 150 



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CONTENTS. Ixiii 

PAOB 

Y. On Gases of Associated Paroyariaa and Yaginal 
' Cysts formed from a distended Gartner's Duct, by 
Amand Bouth .... 152 

May 2nd, 1894- 

Case of Ezomphalic Foetus, shown by Dr. Giles 

and Dr. Pbobyn-Wiluams . 174 

Kidneys from a case of Eclampsia, shown by Mr. 

Cutler . . .' . . 176 

Gangrenous Uterine Fibroid removed by Abdominal 

Hysterectomy, shown by Dr. William Duncan . 181 
Two Cirrhotic and Cystic Ovaries, with Microsco- 
pical Section of same, shown by Dr. Bbmfby . 184 
Ovarian Tumour with greatly enlarged FaUopian Tube, 

shown by Dr. Hobrockb .185 

Dilated Fallopian^ Tube and Ovary, shown by Dr. 

Hayes . . .185 

Bqport of Committee on Mr. Grogono's specimen of 

Foetus Acephalus Acardiacus (p. 65) . 185 

YI. On Intermittent Contractions of Uterine Fibromata 

and in Pregnancy in relation to Diagnosis, by Dr. 

J. Bbaxton Hicks . . .188 

June 6th, 1894— 

Fibroma of the Ovary, shown by Dr. James 

Cbawfobd ..... 190 
Fibroma (?) of the Ovary, shown by Dr. Fbteb 

HOBBOCKB ..... 192 
Large Sarcoma (P) of the Ovary, shown by Dr. Peteb 

HOBBOCKS . . . .192 

Large Fibroid Tumour of the Uterus, shown by Dr. 

Peteb Hobbocks . . . .193 

Uterus with Placenta prsvia marginalis in sUu, shown 

by Dr. G. F. Blackeb .194 

On an Early Tubal Ovum, shown by J. Bland Sutton 195 
Uterine Fibroids, shown by J. D. Malcolm . 200 

Vll. Ligature and Division of the Upper Part of both 

Broad Ligaments, and the result as compared with 

that following removal of the uterine appendages, 

by Dr. Leonabd Bemfby .202 

Yin. A Case of Adenoma of the Portio Yaginalis Uteri 

forming a Depressed Sore or Ulcer, by Dr. James 

Bbaithwaite «... 208 



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Ixiy C0NTKNT8. 

PAOB 

July 4th, 1894— 

The Menstruation of SernnopHhecus enteUua, showif by 
Walter Heaps . . . .213 

Uterine Fibroid undergoing Colloid Degeneration, 
shown by Dr. T. G. Stevens for Dr. Peteb 
HOBBOCKS ..... 225 

IX. Bemarks on Foetal Retroflexion : Report of a Speci- 

men showing Origin of Gluteus Maximus from 
Occipital Bone, by Dr. Lbonabd Remfby . 227 

X. Temperature immediately after Delivery in Relation 

to the Duration and other Oharacteristics of Labour, 
by Dr. Abthub E. Giles . .238 

XI. On the Change in Size of the Cervical Canal daring 

Menstruation, by Dr. G. E. Hbbman . 250 



October 3rd, 1894— 

Incomplete Tubal Abortion, shown by Dr. L. Remfbt 261 
Gestation in a Rudimentary Horn, shown by Dr. L. 

Remfbt . .263 

Cystic Sarcoma of Omentum simulating Ovarian 

Tumour ; removal ; recovery, shown by Dr. 

William Duncan .... 264 
Bq^ort on a Tumour removed from the Abdomen, July 

22nd, 1894, by Dr. William Duncan . . 265 

Dermoid Cyst of Right Ovary; twisted pedicle, shown 

by Dr. William Duncan . .267 

Large Gangrenous Interstitial Myoma of the Uterus, 

shown by Dr. CuLLiNawoBTH . . 268 

Fibro-cystic Tumour of the Uterus removed by Abdo- 
minal Section, shown by Dr. Lewebs . . 270 
Two Cases of Pseudo-Hermaphroditism, by Mr. J. H. 

Taboett . . . . .272 

XII. Three Cases of Pelvic Inflammation attended with 

Abscess of the 0vai7 ; with Clinical Remarks, by 

Dr..O. J. CULLINOWOBTH . .277 



November 7th, 1894— 

B^ort on Dr. Eden's Specimen of Tubal Mole ezhi- 

bited on January 3rd, 1894 . . .301 

Bepofi on Dr. Leith Napier's Specimen of deformed 

FoBtus . . . . .302 



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CONTENTS. IXV 

PAOB 
Primary Oarcinoma of tlie Fallopian Tube, shown by 

Dr. CULLINGWOBTH .... 307 
Ovarian Tumour complicating Pregnancy ; Cyst rup- 
tured during examination; immediate laparotomy; 
recovery, shown by Dr. William Duncan . 312 

Sarcoma of Ovary, shown by Dr. Dakin . . 313 

Concealed Accidental Hssmorrhage ; Foetus, Placenta, 
and Membranes delivered entire, shown by Dr. 
Dakin . . • 314 

Ruptured Uterus, shown by Dr. Blacker • . 316 

Uterine Fibroid, shown by Dr. Galton . . 318 

Xm. A New and Speedy Method of dilating a Rigid Os n 

Parturition, by Dr. Joseph Fabbab . . 321 

XIV. On Atrophy with Collapse (Cirrhosis), Fibroid Dege- 
neration, and Angioma of the Ovaries, by Dr. 
James Bbaithwaite .... 325 
XY. Note on the Importance of Decidual Cast as evi- 
dence of Extra-uterine Gestation, by Dr. W. S. A. 
Griffith ..... 335 

December 5th, 1894— 

Curious Congenital Deformity, shown by Dr. C. H. 
Robebts * . . . . 341 

Ruptured Tubal Pregnancy, shown by Mr. W. Atkin- 
son Stott ..... 343 

Fibroma of Ovary, shown by Dr. Handfield Jones 343 

Hydatids in the Bony Pelvis, by Mr. J. H. Tabqett . 344 
XYI. A Case of Primary Carcinoma of the Body of the 
Uterus in which Vaginal Hysterectomy was per- 
formed, and more than two years have elapsed 
without recurrence; with a Table of Five other 
Cases of Yaginal Hysterectomy for Cancer of the 
Body of the Uterus, by Dr. Lewbbs . . 374 

Index .391 

Additions to the Libbaby .... 407 



vol. xxzvi. / 

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• 




WOODCUTS. 
















Pregnancy and Labour 
Hbbman) : 
Oaael . 


with Bright'a 


Disease 


(Dr. 

• 


G. 


S 


PAOB 
12 


Case II . 


















18 


Oaaelll. 


















24 


Case IV . 


















. 28 


OaseV . 


















. 34 


Case VI . 


















. 88 


Tubal Gestation (Dr. 


W. 


Duncan) : 

















Bight Ovary and Tube, showing Irregular Rupture in 
Tube ..... 

Tube laid open, showing Amniotic Cavity, Foetus, and 
Umbilical Cord surrounded by blood-clot 
Associated Parovarian and Vaginal Cysts (Dr. Routh) 
Kidneys from a Case of Eclampsia (Mr. Cittleb), Chart 
Foetus Acephalus Acardiacus (Dr. Gbooono) : 

Skeletal System of A cephalic Acardiac Foetus % 

Early Tubal Ovum (Mr. Bland Sutton) : 

Fig. 1 — ^Tubal Ovum showing space between Chorion 
and Amnion and the Polar Disposition of the 
Chorionic Villi. (Natural size) . 
Fig. 2. — Diagram of an Early Ovum, to show the arrange- 
ment of the Membranes 
Fig. 3.— A Tubal Mole. (Natural size) 
Foetal Retroflexion (Dr. Rbmfbt) : 
Fig. 1 . 
Fig. 2 . 
Fig. 3 . 

Fig. 4. — Front view 
Fig. 6. — Back view 
Fig. 6 . 
Pig.7 . 

Temperature in relation to the Duration of Labour (Dr. A. E. 

Giles) : 

Chart I. Prevalent ranges of Temperature after Labours 

of different duration .... 

Chart 2. Relation of the Temperature after Delivery to 

the Time of Day at which delivery oecnrs 
Chart 3. Variations of Temperature according to the 
duration of Labour .... 



161 
178 

187 



197 

197 

198 

229 
230 
232 
233 
233 
234 
234 



244 



247 



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PLATES. 

PULTB PAGE 

I. Pseudo-liermapliroditism (Mr. J. H. Taeobtt) . . 274 

n274 

III. ,. ,. ., ,. . . 274 

IV. Deformed Fcetus (Dr. Lbith Napibr) . 304 
y. Specimen of Primary Carcinoma of the Fallopian Tube 

(Dr. 0. J. OULLINGWOBTH) : 

Fig. 1. — The Cancerous Tube laid open . . 310 

^ Fig. 2. — ^A Portion of the External Surface of the 

Ovarian Cyst . . .310 

VI. Hydatids in the Bony Pelvis (Mr. J. H. Taeobtt) : 

Pig. 1.— External Aspect of Right Half of Pelvis, 
showing Excavation of the Ilium and a 
Large Aperture in the Acetabulum 344 

Fig. 2. — Internal Aspect of same Preparation . 344 

VII. Hydatids in the Bony Pelvis (Mr. J. H. Tabobtt) : 

Fig. 3. — Pelvis after Maceration . . . 344 

Fig. 4. — The Upper End of the Bight Femur, showing 

the Fractured Surface . . . 344 

Fig. 5. — Pelvis with last three Lumbar VertebrsB 
and Upper Ends of Femora after Macera- 
tion ..... 344 



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ADVERTISEMENT. 

Thb Society is not as a body responsible for the facts and 
opinions which are advanced in the following papers and com- 
munications read, nor for those contained in the abstracts of the 
discussions which have occurred at the meetings during the 
Session. 

20, Hanotsb Squabb, W. 



LIBRARY AND MUSEUM, 

20, HaNOYBB Si^UABE, W. 



Hours of Attendance : Daily from 1.30 p.m. to 6 p.m. ; and in the 
Evenings on which the Society meets, from 7.15 p.m. to 7.45 p.m. 

AGNES HANNAM, 

Secretary and Librariam. 



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JANUARY 3ed, 1894. 

G. Ernest Herman, M.B., President, in the Chair. 

Present — 31 Fellows. 

George C. Steele Perkins, M.B., C.M.Bdin., was ad- 
mitted a Fellow of the Society. 

G. Gunnis Ferguson, M.B., C.M.Glas. (W. Hampstead) ; 
Frederick William Gordon, L.R.C.P.Lond. (Norwich) ; 
Thomas Herbert Morse, F.R.C.S. (Norwich) ; and Israel 
J. E. Renshaw, F.R.C.S.Edin. (Sale), were declared 
admitted. 

The following gentlemen were elected Fellows of the 
Society :— John Campbell, M.A., M.D., M.Ch.Dubl., 
F.R.C.S. (Belfast) ; Charles Robert Mortimer Green, 
L.R.C.P.Lond. (Calcutta) ; Bruce Hamilton, L.R.C.P.Lond.; 
Alfred Featherstone Kellett, M.B., B.C.Cantab. (Lewisham 
Road, S.E.); Arnold W. W. Lea, M.D., B.S.Lond., 
F.R.C.S. ; Henry Lawrence McKisack, M.D.Dubl. (Bel- 
fast) ; and Hugh R. Smith, M.B.Lond. 

The President nominated Dr. Haig Brodie, Dr. Rivers 
Pollock, and Dr. W. W. Hunt Tate as Auditors of the 
accounts for 1893. 

VOL. XXXVI. 1 



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FIBBOMA SPONTANEOUSLY ENUCLEATED. 



Report of Committee on Dr. Amand RoutWa Specimen of 
Fibroma spontaneously enticleated, shown November 
1st, 1893 ('Transactions/ vol. xxxv, p. 409). 

The specimen consists of a part of the left broad liga- 
ment, with the corresponding Fallopian tube and round 
ligament. At the free end of the Fallopian tube there is 
a hard white globular body, about the size of a Tangerine 
orange. It is closely attached to the extremity of the 
Fallopian tube, some of whose fringes are adherent to the 
exterior of the tumour. The passage of the tube is in no 
way obstructed, for a bristle can be readily passed along it. 

The surface of the tumour is smooth, dimpled in places, 
white and glistening. On section it is found to consist of 
two parts : an outer zone of white, densely fibroid material, 
measuring one third of an inch in thickness ; and a central 
part, one inch in diameter, of a greyish-yellow colour. 
Closer examination shows a thin calcareous plate situated 
immediately beneath the outer zone and involving about 
half the circumference of the centre. Histologically the 
periphery of the growth is composed of almost homo- 
geneous fibroid tissue, and the central part consists of 
looser and more cellular fibrous tissue mingled with 
patches of granular substance which represents degene- 
rated blood-clot. The vessels in the softer portion of the 
tumour are filled with similar matter. 

As regards the origin of the tumour it may possibly 
represent a subperitoneal fibroma of the uterus which has 
become detached; and we are of opinion that in the 
anatomy of the preparation there is nothing inconsistent 
with this view. 

J. H. Taroett. 
W. S. A. GRiFriTH. 
Amand Routh. 



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UTERUS FROM A SEPTIC CASE. 

By Charles Chepmell^ M,D, 

De. Chepmbll showed the reproductive organs of a 
woman who died on the fifth day of her puerperium of 
pnerperal peritonitis. The labour, which resulted in the 
birth of twins, was attended by an untrained nurse or 
midwife — ^who, three weeks previously, lost a case of the 
same kind. The specimen showed the gangrenous condi* 
tion of an unrepaired perineal rupture, and of the fissured 
cervix. The placental sites were uninfected, and the 
tubes were only inflamed at the fimbriated extremities. 
The infection evidently did not spread along the mucous 
surfaces, but through the lymphatics directly from the 
infected spots. 



HYPERTROPHIED NYMPHS AND CLITORIS. 

By William Duncan, M.D. 

A cOMMirrEE, consisting of Drs. Horrocks, Tate, and 
Duncan, was appointed to report on this specimen. 



A MALFORMED HEART. 

By R. J, Probyn-Williams, M.D. 

The specimen, which as far as can be ascertained is 
unique, was removed from a child born at full term at 
the General Lying-in Hospital. From the time of its birth 



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4 HTDBOCEPHALUS WITH SPINA BIFIDA. 

the cliild was always of a bluish colour^ occasionally 
'becoming almost black and quite cold. 

The apex was to the right of the sternum^ but no mur- 
mur could be detected. 

The child lived a fortnight in the hospital^ gradually 
wasting^ and died fourteen days after discharge. 

On post-mortem examination the heart was found to 
consist of two ventricles with only one auricle. 

Into the auricle opens a superior vena cava which is of 
large size^ and there is only a trace of a septum at the 
upper and back part. 

There is a pulmonary artery arising from the right 
ventricle, but it is not patent ; and there is a well-developed 
ductus arteriosus arising from the aorta, which is normal. 

The left pulmonary vein has apparently opened into 
the vena cava, and on the right side there is only a small 
loop with no opening. 



HYDROCEPHALUS WITH SPINA BIFIDA. 
By R. J. Pbobyn-Williams, M.D. 

The specimen shown was extracted from a patient in 
the General Lying-in Hospital. 

She had been in labour for six days when first seen, 
and the condition on examination was somewhat unusual. 

The finger passed through the external os, which was 
fairly well dilated, and felt a soft, doughy swelling, round 
which the finger could be swept without discovering any 
hard parts. 

After admission to the hospital, the patient was anaes- 
thetised and another examination made. 

The swelling which had been felt was then found to be 
about as large as an ordinary foetal head at full term, and 
above it, three' inches from the external os, was a tight 



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UNBUPTUBED TUBAL OBSTATIOK. 5 

constriction-— Bandies ring, — ^and above this again the 
bones of the skull in the second cranial position. 

The presenting part was perforated and the child 
extracted hj means of the cephalotribe. 

The following are the principal measurements of the 
head as distended with' tow: — ^Bi-parietal diameter 5|- 
inches ; bi-temporal, 5 inches ; fronto-occipital, 6^ inches ; 
mento*occipital, 7^ inches ; maximum vertico-mental, 7f 
inches ; snb-occipito-bregmatic, 6 inches ; sub-occipito- 
frontal, 5i inches; fronto-occipital circumference, 20 inches; 
-sab-occipito-bregmatic, 18^ inches ; from ear to ear over 
the bregma, 14 inches. 



UNRUPTURED TUBAL GESTATION. 
By T. W. Edkn, M.D. 

Db. Eden said that the specimen was from a case 
operated upon in the Chelsea Hospital for Women by Dr. 
Schacht on October 14th, 1893. The parts removed con- 
sisted of the left tube and ovary which were now shown. 
The distal half of the tube was distended to the size (in 
the fresh state) of a Tangerine orange, and its contents 
were fluctuating. The ovary was enlarged to the size of 
a pigeon's egg, and presented a ruptured cyst upon its 
surface containing some dark granular blood-clot. In 
order to preserve the relations of parts, the entire specimen 
was frozen, and the tube opened by a longitudinal incision. 
It contained in its outer half an oval laminated mass of 
blood-clot, but no trace was evident to the naked eye of 
foetus or foetal appendages. The inner half of the tube, 
which was unoccupied by blood-clot, was dilated without 
thickening of the walls, and contained a clear fluid. The 
uterine ostium was patent ; the abdominal ostium was 
occluded and all traces of the fimbriae had disappeared. On 



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6 UKBUPTURID TUBAL OBSTATIOK. 

microscopic examination of portions of the blood-clot taken 
from different parts^ structures were found which he be- 
lieved to be undoubted chorionic villi. They were very 
well represented in the drawings which had been executed 
by Dr. Giles. They were definite structures, quite dis- 
tinct from the surrounding blood-clot, consisting of nu- 
cleated cells and a little delicate fibrous tissue; there were 
no vessels visible in them. The surface layer of cubical 
epithelium could be distinctly made out in nearly every 
instance, but the cell outlines were obscured by the depo- 
sition upon them of a layer of fibrin, as well as by degene- 
rative changes. 

From the clinical history, the gestation could not be 
further advanced than ten to eleven weeks. Dr. Eden's 
view was that the ovum had perished considerably earlier 
than that by haemorrhage into its substance, very probably 
repeated haemorrhage. The foetus and foetal appendages 
had been entirely absorbed, with the exception of the 
chorionic villi, and they had undergone considerable dege- 
neration. It was interesting to notice that the entire tube 
was dilated ; in tubal gestation the part occupied by the 
ovum was usually not much dilated, and the question arose 
whether this tube could have been the seat of salpingitic 
dilatation before the fertilisation of the ovum. 

The case was important inasmuch as specimens of un- 
ruptured tubal gestation were very rare, there being only 
three or four previously recorded cases. 



Dr. William Duncan thought the case very interesting, and 
although chorionic villi were shown under the microscope, thus 
proving the accuracy of the diagnosis, he hoped the President 
would appoint a sub-committee to report on the specimen. He 
asked Dr. Eden what were the symptoms which caused abdominal 
section to be performed in the case of a tubal gestation where the 
foetus was thought to be dead. 

Mr. Alban Doban observed that Dr. Eden's case was very 
similar to one in his own experience, a " Case of Tubal Abor- 
tion," reported in the * British Medical Journal/ voL ii, 1891. 
In both cases structures like chorionic villi were found in the 
clot. Care must be taken not to mistake fibrinous deposits for 



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UNRUPTURED TUBAL GESTATION* 7 

▼illi. In bflemorrbage into the tube occurring in the early stages 
of tubal gestation^ the ostium was usually not only open but 
dilated ; yet it was easy to understand that the ostiuin might 
become closed under similar circumstances. 

Mr. Bland Sutton had no doubt that the body in the tube 
was a tubal mole ; had there been a doubt the sections exhibited 
under the microscopes would completely dispel it, for among the 
clot there were many typical chorionic villi in transverse section. 
The fact that the abdominal ostium was occluded had an interest 
for him, as he had come to the conclusion, from an examination 
of many specimens, that it required from eight to ten weeks after 
impregnation to effect this closure ; the clinical facts of this case 
supported his conclusion. Mr. Sutton considered that the re- 
moval of such a gravid tube was correct practice. 

Mr. DoBAN added that it was important to remember that 
Mr. Sutton and himself had to a great extent verified their 
researches by examining clot in tubes where a minute foetus 
was actually found. The chorionic villi were very distinct in 
sections from these cases, and formed a reliable standard of 
comparison. 

Dr. ScHACHT said that the history was briefly as follows : — 
Patient aged 29 ; married five years, never pregnant ; catamenia 
regular, never missed ; last period three and a half weeks ago, 
duration four days, quantity normal ; ten days before coming to 
the Chelsea Hospital there was a slight show which lasted some 
days. The day after the appearance of this show there was 
sudden pain in the morning in the left inguinal region, lasting 
two hours. The second attack of pain occurred four days 
later while in bed. The third attack of pai n, three days later (the 
day before coming to the hospital), it came on while washing ; 
this was more acute than the others, and lasted one and a half 
hours. Examination showed her to be losing slightly ; the uterus 
was normal in size ; the cervix somewhat softened, while to the 
left of the uterus was an apparently enlarged and tender tube. 
Temperature 100®. She was admitted at once. With rest in 
bed the patient went comfortably through what appeared a normal 
period, and as the tube became much less tender she was allowed 
to go home on condition that she remained in bed. About two 
months from the date of first being seen, she had another bout 
of sharp pain, preceded by a profuse period which came at the 
proper time. On examination the mass appeared distinctly larger, 
about the size of a Tangerine orange, with a pulsating vessel 
plainly to be felt along the lower border. She was re-admitted 
and operated on without delay. The main points in diagnosis 
were — (1) irregular loss though no history of decidua; (2) re- 
curring bouts of sharp pain in the left iliac region ; (3) presence 
of tube dilated, probably with blood ; and (4) a pulsating vessel. 
The pathological condition had been carefully described by 



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8 XWBUFTUBBD TUBAL 0B8TATI0K. 

Dr. Eden, and he (Dr. Schacht) would of course be very pleased 
to have the report of such a committee as had been proposed on 
the specimen. 

The Pbbsidbnt thought there could be no doubt that Dr. 
Eden's specimen was a tubal gestation. The specimen of 
unruptured tubal jpregnancy which he (the President) had 
Temoved and described, and to which Mr. Bland Sutton had 
referred, differed from Dr. Eden's. In it blood was effused in 
the chorion outside the amnion, and the amniotic cavity contained 
a foetus. The patient's symptoms were trifling, and the opera- 
tion was done, not to reHeve symptoms, but because the dia- 
gnosis of extra-uterine pregnancy nad been made. It was not 
possible to ascertain whether the pregnancy was going on, or 
whether death of the foetus had occurred, except by waiting and 
watching, which delay, if the pregoancy was going on, would 
put the ^tient in peril of rupture and intra-peritoneal heemor- 
rhage. To avert this danger the operation was done. Similar 
considerations, he thought, entirely justified Dr. Schacht in 
operating on his patient. 

A Committee, consisting of Mr. Bland Sutton, Mr. 
Alban Doran, and Dr. Eden, was appointed to report on 
this specimen. 



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SIX MORE CASES OP PREGNANCY AND 
LABOUR WITH BRIGHT'S DISEASE. 

Bt G. Ernest Herman, M.B.Lond., F.B.C.P., 

OBSTBTBIO PHTSICIAV TO THI LONDOV HOSPITAL, STO. ; 
P&BSISBNT OP THS 80CIBTT. 

(Received November 15th, 1893.) 

{Abstract.) 

Ca8B 1. Third pregnancj. Eclampsia with second labour, and 
persistent subsequent albuminuria. Third pregnancy beginnin g 
eleyen months afterwards. (Edema and short breath coming ou 
in second month of pregnancy. Arterial degeneration. Cardiac 
hypertrophy. Old retinitis. Urine containing one third albu> 
men and casts. Premature delivery at end of fifth month. No 
fits. Slight diuresis following delivery. No marked diminu- 
tion in albumen immediately following delivery, but some dimi- 
nution following prolonged rest. Percentage of urea much, 
and absolute quantity of urea somewhat, below the average. No 
marked alteration in urea percentage accompanying delivery. 
Death six months afterwards. 

Case 2. Tenth pregnancy. Ill twelve months before delivery. 
Urine containing half albumen. Polyuria. Deficient urea 
elimination. Bronchitis. No retinitis. Labour induced in ninth 
month. Death of child on delivery. Persistence of bronchitis. 
Diarrhoea. Increased urea excretion and diminution of albu- 
minuria following delivery. Irregular slight pyrexia. Death 
a month afterwards. Chronic tubal nephritis. 

Case 8. Fifth pregnancy. Bone disease followed by amputa- 
tion of thigh eleven years previously. (Edema dating from 
fourth labour, four years previously. No other symptoms. 



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10 PEBGNANCT AND LABOUR WITH BEIOHT's DISEASE. 

Ansemia. Ko retinitis. Polyuria. Urine containing half albu- 
men, almost entirely serum-albumen. Slight diminution of 
albumen under milk diet. Urea excretion only slightly below 
normal. Labour induced at eight months. Child living. Diu- 
resis, increase of urea elimination, and still greater diminution 
of albuminuria following delivery. Good health two years after- 
wards, in spite of persistent albuminuria. 

Case 4. First pregnancy. Symptoms beginning towards end 
of seventh month. No retinitis. Urine containiog two thirds 
albumen and casts. Labour induced at end of eighth month. 
Increase of albuminuria during labour. Progressive diminution 
duriug lying-in. Slight deficiency of urea elimination. Slight 
polyuria before delivery. Diuresis following delivery. Child 
living. Piece of placenta retained, and removed on the ninth 
day. Good health eleven months afterwards. 

Case 5. Second pregnancy. Symptoms three weeks before 
term. Vomiting. Diarrhoea. (Edema. Labour at term. 
Lingering first stage accelerated by bougie. Child living. 
Urine containing casts, and a quarter albumen. Increase of 
albuminuria to one half during labour. Diuresis after delivery* 
Diminution of albuminuria during lying-in. Slight diminution 
in urea excretion. Good health and freedom from albuminuria 
six months afterwards* 

Case 6. First pregnancy. Symptoms a week before admis- 
sion. (Edema. Weakness ; short breath. Cardiac hypertrophy. 
Urine containing one third albumen. Labour induced at end of 
eighth month. Child living; no fits. Slight deficiency of 
urea elimination. Diuresis, increased urea elimination, and 
diminution of albuminuria following delivery. Good health 
a year and eight months afterwards. 

The author compares these cases with others reported in 
former communications by him to the Society, in all eleven in 
number, and then compares these eleven cases with twelve cases 
of puerperal eclampsia, also published by him in the Society's 
' Transactions.' He draws the following general conclusion : — 
There are at least two kinds of renal disease to which a preg- 
nant woman is specially liable. One of these is a very acute 



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PREGNANCY AND LABOUR WITH BBIGHT^S DISEASE. 11 

diflease, in wliicli premonitory symptoms are either absent 
or of duration measurable by hours or days. It attacks 
chiefly primigraTidse. It often causes iutra-uterine death of 
the child. It is attended with extreme diminution of the 
quantity of urine, and the small quantity of urine that is 
passed is greatly deficient in urea, but contains enough albu- 
men to make it solid on boiling. This disease is accompanied 
with rapidly recurring fits. If it run a favourable course, the 
fits cease, then the urine increases in amount, and the percent- 
age of urea in it rises. If the excretion of urea be not re- 
established, the case quickly ends fatally. Such cases seldom, 
if ever, pass into chronic Bright' s disease. 

The other is a disease which attacks older subjects, chiefly 
those who have had children before. Its premonitory symptoms 
extend over a period measurable by weeks or months. It often 
leads to intra-uterine death of the child. It is accompanied 
generally by increase in the quantity of urine, with copious loss 
of albumen, but not so much in proportion to the urine as in 
the more acute disease, and with diminution in the elimination 
of urea, but not nearly so great a diminution as in the more 
acute disease. Delivery is followed by temporarily increased 
diuresis and increase in the urea elimination. When this 
increase is considerable, the albuminuria usually diminishes and 
disappears, and the patient gets well. When the increase is 
only slight the albuminuria ^^ersists, and the case becomes one 
of chronic Bright' s disease. This form of disease is sometimes 
attended with fits, but generally not. The presence of albu- 
minuric retinitis affects the prognosis unfavourably. When the 
pressure within the abdomen is greater than usual, the amount 
of urine may be diminished, but in such cases the diuresis and 
the augmentation of the urea elimination after delivery are 
proportionately greater. 

In the acute disease which causes eclampsia, and in the 
chronic disease when it is associated with excessive intra-abdo- 
minal pressure, much of the albumen is paraglobulin. The 
cases in which the albumen is mainly serum-albumen generally 
either die or pass into chronic Bright's disease. 

Ik former communications (vols, xxxii and xxxiii) I 
have put before the Society cases of albuminuria compli- 



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12 PBBOKANCT AND LABOUR WITH BBIOHT's DI8BA8B. 

dating pregnancy^ with and without eclampsia^ in which the 
character of the urine had been observed with especial 
care. In the present paper I relate some further cases of 
the same kind. 

Cask 1. Third pregnancy ; eclampsia with second labour 
and persistent subsequent albuminuria ; pregnancy 
eleven months afterwards. (Edema and short breath 
coming on in second month of pregnancy ; arterial 
degeneration; cardiac hypertrophy; old retinitis; urine 
containing one^third albumen and casts ; premature 
delivery at end of fifth month ; no fits ; slight diuresis 
following delivery; no marked diminution in albumin 
immediately following delivery, but some diminution 
following prolonged rest; percentage of urea much, and 
absolute quantity of urea somewhat, below the average; 
t^o marked alteration in urea percentage axicompanying 
delivery ; death six months ajterwards. — C. K — was de- 
livered of a dead child in January, 1889, labour being 
attended with eclampsia. Her case is reported in the 
' Transactions/ vol. xxxii, p. 26. 

She was again admitted into the London Hospital, April 
7th, 1890 (for the notes on this occasion I am indebted 
to Dr. A. B. Roxburgh, Resident Accoucheur, and Mr. 
W. H. Sturge, clinical clerk) . Patient menstruated three 
months after leaving the hospital, and continued to do so 
regularly until five months ago, the flow being rather 
less copious than formerly. For the last five months has 
seen nothing. During the last four months has felt '^ ill 
in herself ; '' has suffered from swelling of the face and 
legs, the latter mostly in the evening. For three weeks 
has had a pain in the back and belly, worse at night and 
when lying down, and also difliculty in breathing. 

On admission, the uterus presented the characters of 
five months' pregnancy. Slight oedema of legs. Arteries 
hard. Aortic second sound accentuated. Heart's apex- 
beat outside nipple line. No abnormal signs in lungs. 
Old retinitis albuminurica, but no recent changes. Urine 



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14 

smoky, containing one-third albumen, deposits of blood- 
corpuscles, epithelium and granular casts. 

April 11th. — During yesterday patient had severe pain 
in the lower belly and loins. In the evening six leeches 
were applied to the loins, and this was followed by relief 
from the pain. Shortly before midnight the patient felt 
something give way, and there was a watery discharge 
from the vagina. At 7 a.m. this morning a female foetus, 
measuring ten inches long and weighing 10 ounces, was 
expelled with its placenta and membranes. The placenta 
weighed 3 ounces. Evening temperature 101°. 

Patient recovered from the abortion without unusual 
hsDmorrhage, Temperature was normal on April 14th and 
afterwards. In other respects her condition continued 
much the same as on admission. She left the hospital on 
April 30th. During her stay in hospital she had no fit, 
nor anything like the premonitory symptoms of a fit. 
Her weight while in hospital decreased from 7 st. 8 lbs. to 
7st. I have no record of her weight at the time of the 
labour, 

January, 1891. — I learn from the patient's friends that 
she died in October, 1890. 

Urine : Quantity. — The quantity of urine was less 
above the average than during childbed sixteen months 
previously. Then the average daily excretion was 
58 i ounces. On the present occasion the daily average 
was 46 ounces: Both these averages are exclusive 
of what was unavoidably lost with the stools. On 
the day following the miscarriage there was diuresis, 
as there was on the second day following the delivery. 
This diuresis was only temporary, and was followed, after 
labour and after delivery, by a fall, and then a rise again 
to about the average. After labour^ the rise in quantity 
was slower and greater, and the subsequent drop also 
greater and more prolonged, than after the miscarriage. 

Spedjic gravity, — I unfortunately have no record of 
this till April 15th. From that date onwards it only varied 
between 1010 and 1012, except on April 22nd (eleventh 



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PBEONANCT AND LABOUB WITH BBIQHT^S DISEASE, 15 

day of lying-in), when it sank to 1005, On this day there 
was increased diuresis. 

Albumen. — When the patient was discharged from the 
hospital after her confinement, the urine contained from 
one-fourth to one-third its bulk of albumen. On admission, 
before the miscarriage, the albumen was from two-fifths 
to one-third. This remained about the same until the 
eleventh day of the lying-in, when it sank, first to one- 
fourth, then to one-fifth, then to one-sixth. 

Deposit, — ^The urine throughout gave a deposit of pus 
and granular casts, with some blood when first admitted. 

Urea. — ^The percentage of urea roughly corresponded 
to what would have been expected from the specific 
gravity of the urine, and therefore the fluctuations of 
the urea excretion show a general correspondence to those 
of the quantity of urine. It averaged 191 grains per 
diem. On the occasion of the delivery of a child it 
averaged throughout 265 grains per diem. Both these 
quantities are exclusive of what was lost with the stools. 

Sugar. — ^The urine never contained sugar. 

Reaction. — The urine was acid throughout. 

This case is interesting, first, as being a complete 
history of a case of Bright' s disease coming on in preg- 
nancy, I have published another in the ' Transactions,' 
vols, xxix and xxx. The total duration of the illness 
in that case was eleven months ; of this one two years. 

Secondly, compared with others, it helps to show the- 
effect of abdominal distension on the renal function. I 
have put before the Society cases which tend to show that 
a diuresis following delivery is the rule ; that when the- 
distension is very great, the diuresis following its removal 
is greater than usual (see case, vol. xxxii, p. 327) ; that 
when the distension is less than usual, the diuresis is slight 
(see case, vol. xxxii, p. 335), In this case the abdominal 
distension was very slight, and the diuresis was scarcely 
appreciable. 

Thirdly, that in this case, in which the renal disease 
persisted, and cardio-vascular changes developed, the urine- 



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16 PBEONANCT AND LABOUB WITH BRIGHT' S DISEASE. 

never presented the characters usual in the cases of sadden 
eclampsia which get well^ viz.^ loaded with albumen^ 
•diminished in quantity, and of high specific gravity. 

Case 2. Tenth pregnancy ; ill twelve months before 
delivery; urine containing one half albumen; polyuria; 
deficient urea elimination ; bronchitis ; no retinitis ; labour 
induced in ninth month ; death of child in delivery ; per- 
sistence of bronchitis ; diarrhoea ; increased urea excretion 
and diminution of albuminuria following delivery ; irregu- 
lar slight pyrexia ; death a month afterwards ; chronic tubal 
nephritis. — R. J — , aet. 32, admitted into the General Lying- 
in Hospital January 1st, 1890. (For the notes of the case 
and the analysis of the urine I am indebted to Mr. C. H. 
•James, House Physician to the hospital.) 

No previous illness except confinement. Never had 
scarlet fever nor rheumatic fever. First menstruated at 
fourteen, flow always scanty, usually lasting three days 
and irregular, the intervals varying from one to three 
months. Had always been temperate and had sufficient 
food. Was married at nineteen, and had had six children 
and three miscarriages ; the last child in April, 1888 ; last 
miscarriage at three months— in April, 1889. All labours 
natural, excepting that the last was finished by forceps. 
The last menstruation ceased on January 20th, 1889. 

Patient said that for twelve months she had been 
getting ill and weak. She often felt faint, and in the 
summer she twice fainted. Had had a cough throughout 
pregnancy. Some nausea in the early part of pregnancy, 
but no vomiting. For a month had suffered from sleep- 
lessness. For about the same time micturition had been 
more frequent than before. Legs had swelled, and lower 
abdomen been puffy, for about three weeks. For two 
weeks she had been under medical care, keeping her bed 
and taking no solid food, although appetite was fair. 
During this time she had been passing more urine than 
usual, and it had been very high-coloured. Bowels 
regular. 



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FBEONANCY AND LABOUB WITH BAIOHT's DISEASE. 17 

On admission patient did not appear ansBmic, but was 
tliin and pale. There was much oedema of legs^ labia^ and 
abdominal wall. Fundus uteri reaching three-quarters of 
distance between umbilicus and ensiform cartilage. 
Greatest girth of abdomen 39^ inches. FoBtal head felt in 
left iliac fossa. Cervix uteri just admitting finger, but 
cervical canal not obliterated. FoBtal heart heard. 
Heart's apex-beat just within nipple line. Sounds normal 
at apex : at base first sound prolonged, second sound 
accentuated. Loud rhonchi heard over both lungs. No 
ophthalmoscopic changes. Urine containing half its bulk 
of albumen ; blood, pus, and epithelium ; hyaline and 
blood casts. 

January 3rd. — Patient takes food well. Does not* sleep 
well. No oedema of arms or face ; no ascites. Impaired 
resonance over chest, feeble breath-sounds at most parts, 
loud rhonchi over right lung; absent breath-sounds and 
vocal fremitus at both bases. 

4th. — 11 a.m. a bougie was introduced (with antiseptic 
precautions). 

5th. — Patient slept four hours last night, having been 
given a draught of chloral and potassium bromide. Patient 
more anaemic ; oedema increasing ; no pains. Bougie 
partly slipped out. At noon the smallest sized BsLmes's 
bag was introduced. 

6th; — ^After the introduction of Barnes's bag, patient 
had pains increasing in frequency and force till 5 a.m. this 
morning. Then they became less frequent, and patient 
slept. On examination later on, the bag was found to 
have been expelled into the vagina, and was removed. 
Vagina douched with 1 in 2000 sublimate solution, and 
the largest size Barnes's bag introduced into cervical canal. 
Patient complains of thirst, and is low spirited. 

7th. — ^After introduction of largest Barnes's bag yester- 
day morning there were labour pains every ten or twelve 
minutes until between 2 and 3 p.m., when they ceased. 
On examination at 6 p.m. the bag was found expelled into 
the vagina, and was removed. A bougie was put into the 

VOL. XXXVI. 2 



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18 PREQNANCT AND LABOUR WITH BEIQHt's DISEASE. 

uterus and left there during the night, but did not produce 
uterine contractions. The rhonchi over the lungs have 
diminished ; there is resonance over the bases behind, but 
the breath-sounds are still feeble. CBdema less. Fcetal 
heart heard. Breath slightly offensive. 

8th (evening). — Complains of neuralgia in face. Had 
a draught of chloral and bromide last night; the same 
ordered for to-night. Four bougies, and the largest size 
Barnes' bag put into the uterus. 

9th (morning). — ^No pains. Breath very offensive; some 
swelling below jaw on both sides. 

1 p.m. — Labour pains began. 

8 p.m. — Head presenting, and cord pulsating feebly in 
front of it. 

10 p.m. — Os fully dilated. Patient put under chloro* 
form, membranes ruptured, and podalic version performed,, 
left foot being brought down, and subsequently the right. 
Some difficulty in extracting the head, owing to its having 
become extended. It was delivered with forceps at 10.30 
p.m. 

10.40 p.m. — Placenta expressed. About 10 ounces of 
blood lost. Intra-uterine hot sublimate (1 to 2000) douche 
given. Child stillborn. Attempts at resuscitation failed. 

10th. — Bronchitis worse. Severe frontal headache. 
Breath very offensive. 

11th. — Breathing has been very weak and shallow, and 
patient at times felt very faint, so that at times she thought 
she was sinking. Slight delirium between sleeping and 
waking; at other times mental condition clear. Slept 
well. Chest rubbed with 01. Terebinth, and 01. Olivce, 
with marked relief to breathing. 

12th.-^Severe diarrhoea, with colic and tenesmus ; stools^ 
watery. Tr. Opii rt{x given as enema. Cough better. 
Takes food well. CEdema of legs gone. No dulness over 
lung bases, nor diminution of breath-sounds. Ordered 
Tr. Ferri Perch. Tn.xx, Spt. Chlorof. t^xv, three times 
daily. 

1 3th. — Diarrhoea nearly ceased. Taking food well. By 



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20 PREGNANCY AND LABOUR WITH BRIGHt's DISEASE. 

abdominal examination both kidneys can be felt to be en- 
larged, but are not tender. 

14tli. — Patient cheerful and comfortable. Appetite good. 
Has slept well. No pain. Diarrhoea ceased. Foetor of 
breath less. Submaxillary glands have been much swollen, 
and are still somewhat swollen. There has been no marked 
salivation. No oedema anywhere. 

16th. — Foetor of breath gone, but patient still complains 
of a metallic taste in mouth. Gums bleed easily. Bowels 
slightly loose, but no pain. 

21st. — Patient allowed to sit up. No soreness of gums, 
but still metallic taste in mouth. Cough nearly gone. 
Ophthalmoscopic examination shows nothing abnormal. 

23rd. — Urticaria on thighs. Yesterday there was pain 
in right calf. To-day there is also tenderness and fulness 
of the veins. No oedema. Leg put into cotton wool and 
bandaged. 

25th. — Patient examined. Uterus quite moveable. 
Kidneys still enlarged. 

28th. — Rigor, supposed to be due to fish not agreeing 
with her. 

30th. — Patient discharged at her own wish. She is sallow, 
and thinner than she was on admission. No oedema. No 
bronchitis. Kidneys still large. 

February 3rd. — Patient was admitted into the London 
Hospital. 

9th. — She died. The autopsy showed both kidneys 
enlarged by chronic tubal nephritis. 

Temperature. — On admission, and while anything was 
done to bring on labour, the temperature was normal. 
On the evening of the day following delivery the tempe- 
rature rose to 104'8®, but the next day quickly fell to 
below normal. This was attributed to the bronchitis and 
bowel disturbance. On the evening of the fourth day of 
childbed there was another rise, reaching 102'8^. Fulness 
and pain in the breasts was believed to be its explanation. 
There was a rise to 101*8° on the eighth day, and to 101® 
on the ninth day ; and after the thirteenth day there was 



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elevation of temperature in most evenings, without notable 
acceleration of pulse or changes in the patient's condition 
to account for them. I can only attribute them to the 
changes going on in the kidneys. 

Urine : Quantity. — This was throughout above the 
average of health. An attack of diarrhoea which fol- 
lowed delivery unfortunately prevented the immediate 
effect of labour on the quantity of urine from being ascer- 
tained. The average daily amount of urine before 
delivery (taking the days on which all or nearly all the 
Brine was collected) was 75 ounces. The average daily 
amount during the lying-in, beginning on the seventh 
day, was 83 ounces; but there were very great fluctua* 
tions, the daily amount ranging from 36 to 110 ounces. 
I am not able to identify any changes in the patient to 
explain these variations. 

Urea. — The quantity of urea was estimated by Squibb's 
apparatus. It shows throughout an excretion below the 
average. During eight days preceding delivery it aver- 
aged 152*5° grains per diem. After delivery it was 
slightly increased, averaging between the seventh and 
thirteenth days of the lying-in 203*4 grains per diem. 
On the fifteenth day of the lying-in it suddenly shot up 
to 578 grains. I am not able to offer any explanation of 
this sudden increase. Mr. James tells me that he was 
under the impression at the time that it was due to the 
patient's taking proteids more freely; but although the 
diet prescribed for the patient is recorded, yet I have no 
notes as to what she actually ate, and therefore I cannot 
say whether this is so or not. It might be suggested 
that the former low quantities were due to a leak in the 
apparatus, allowing the escape of gas. But Mr. James 
tells me that he does not think the apparatus was def ec« 
tive in any way. If defective, it is surprising that the 
defect should have spontaneously corrected itself after a 
fortnight's use. Defective manipulation allowing gas to 
escape might account for low quantities. But I have 
entire confidence in Mr. James's care ; and if error of this 



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22 PREGNANCY AND LABOUR WITH BRIGHt's DISEASE. 

kind did occur, it is surprising that it should have 
occurred with such regularity during a fortnight, and 
allowed the escape of nearly the same quantity of gas 
each time. I believe the records are correct, excepting 
that some urine was lost when the bowels acted. 

Specific gravity, — This was 1015 on admission and the 
day following. During the rest of the patient's stay in 
hospital it only varied between 1008 and 1010, more 
often the former. 

Alhnmen. — On admission the urine contained half its 
bulk of albumen. A week after admission, before de- 
livery, it had sunk to a mere trace. On the fifth and 
sixth days of the lying-in it had slightly increased, 
amounting to one-eighth ; then it sank again to a trace, 
and remained only this until the patient's discharge. 
The relative amounts of paraglobulin and serum-albumen 
were not ascertained. 

Bepofdt, — On admission the urine gave a deposit of pus, 
epithelial cells, granular and hyaline casts. Six days 
after admission it was again examined microscopically, 
and found to contain blood-corpuscles in addition to the 
above elements. 

Case 3. Fifth pregnancy ; hone disease , followed by 
amputation of thigh eleven years previously; oedema 
dating from fourth labour four years previously, but no 
other symptoms ; anrnmia ; no retinitis ; polyuria ; urine 
containing half albumen, almost entirely serum^albumen ; 
slight diminution of albumen under milk diet ; urea excre^ 
tion only slightly below normal; labour induced at eight 
months ; child living ; diuresis, increase of urea elimina^ 
tion, and still greater diminution of albuminuria following 
delivery; good health two years afterwards. — Mrs. C — , 
set. 38, married twenty years, admitted to General Lying- 
in Hospital January 5th, 1891. 

Previous history (reported by Mr. H. B. Osburn, House 
Physician). — Had measles, not scarlet fever. Began to 
menstruate at sixteen ; severe pain before marriage, which 



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PBKONANCY AMD LABOUR WITH BRIGHT^S DISEASE. 28 

ceased after marriage. In her twenty-seventh year her 
right leg was amputated for disease of the bone, which had 
been going on for two years, and after a previous excision 
had failed. She has also a scar on the right arm, which 
she says was left by an operation for the removal of some 
diseased bone there. She has had four children. There 
was an interval of nine years between first and second. 
The labours all easy except the last, which was tedious. 
The last confinement was four years ago. Patient got up 
as usual after this confinement, but noticed at this time 
slight oedema of feet and puffiness of face. 

Her medical attendant considers that the renal disease 
dates from this time, and she comes here at his suggestion 
to see what had better be done in the present pregnancy. 
Patient last menstruated April 28th — May 3rd, 1890. 
Quickening was felt in August, 1890. Her health during 
the pregnancy has seemed very good. She had no morn- 
ing sickness, but has had slight nausea on rising during 
the later months. She has had no headache, no loss of 
appetite, no pain, and no vaginal discharge. Her sight 
has been pretty good. During the last few weeks she 
has noticed herself becoming a little deaf. 

On admission. — Patient is well developed and nourished, 
but her skin is, however, waxy in appearance, her face 
very puffy, and mucous membranes pale. 

Chest. — Lungs resonant all over, nothing abnoiTnal. 

Heart. — Dulness normal, accentuation of second sound 
at base, soft systolic murmur at aortic area. 

Abdomen. — ^A good deal of oedema in hypogastric 
region. On palpation fundus uteri felt 5| inches above umbi- 
licus. Heart sounds two inches to right of and one inch 
above umbilicus ; 140 per minute. There is some oedema 
of the stump of the right leg. The left leg and foot are 
slightly oedematous ; no varicose veins. 

Per vaginam, cervix almost obliterated, os quite pa- 
tulous, admits two fingers ; cranial presentation. No defor- 
mity of pelvis. Sacral promontory not felt. Some oedema 
of vulva. 



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24 PREGNANCY AND LABOUR WITH BRIGHT's DISEASE. 

Ophthalmoscopic examination. — There is some oedema of 
the retina, but nothing further detected. 

January 11th. — Patient has now been five days on diet 
of Oiij milk per diem. The albuminuria is about the same. 
General condition unaltered. 

At 12 noon a 1 — 1000 mercuric perchloride douche was 
given, and afterwards a bougie passed up the wall of 
uterus. There was a slight escape of liquor amnii. 

12th. — No labour pains. A little liquor amnii has 
escaped. 

16th, 12 noon. — No pains, second bougie put in ; os size 
of a two-shilling piece, head plainly felt, slight show. 

4 p.m., slight labour pains. 

7 p.m., strong pains, and child bom suddenly. Shortly 
before birth patient's temperature reached 101°, and she 
had a ifigor. 

The child was living, 20 inches long, dnd weighed 5 lbs. 
with 5 oz. 

Patient was given fish on the sixth day, and meat diet 
a mixture containing iron on the ninth day. 

She left the hospital on the fourteenth day for the 
London Hospital. She had then much improved ; had 
more colour and less oedema. The urine then contained 
one-sixth albumen. The child was living, it had been 
hand-fed throughout, the mother never suckling it at all. 

The patient was in the London Hospital under the care 
of Dr. Gilbart Smith until February 17th, 1891. When 
discharged the urine still contained one-sixth albumen. 
The amount of urine collected averaged 47 oz. per diem. 
The patient felt and thought herself well when she went 
out. 

March 28th, 1892. — ^In answer to a letter 6i inquiry 
patient writes, " I am better at present than I have been 
during the five or six years I have suffered with kidney 
trouble. I am glad to say I got over the last confinement 
better than the one in Marqh, 1887. 

January, 1893. — ^TJrine still contains half albumen. 

Remarks. — ^Patient had no fits or any symptoms which 



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26 PREGNANCY AND LABOUR WITH BRIGHt's DI8BABE. 

suggested eclampsia^ either before, during, or after 
labour. 

Urine : Qtuintity. — The quantity of urine was through- 
out above the average. During the nine days before deli- 
very the quantity collected averaged 60 oz. per day. 
During the thirteen days after delivery it averaged 62 oz. 
per day. Delivery appears to have been followed by 
diuresis, although this effect is not so marked as in 
other cases that I have published ; for on the fifth day the 
maximum amount collected on any day was reached, viz. 
88 oz. On the second and on the fourth days of the lying- 
in, only 27 and 43 oz. respectively were collected. These 
small quantities may perhaps be accounted for by imperfect 
collection of the urine ; but I think not entirely, for the 
drop in the quantity of urine was accompanied by a rise in 
the specific gravity. 

Albumen. — On admission it was five-eighths, but with 
rest in bed and milk diet it became three-eighths, steadily 
maintaining this quantity until delivery. After delivery 
it gradually decreased for three days, at the end of that 
time averaging about one-fifth, which it remained at, with 
small variations, until the patient's discharge. It was 
tested frequently for paraglobulin, but never more than 
a trace was found. 

Urea. — In the week preceding delivery the average 
daily excretion of urea was 280 grs. ; it showed a slight 
rise during this time, although the diet was restricted to 
three pints of milk a day. It rose immediately after 
delivery, averaging then 420 grs. A further very marked 
rise was seen when fish and meat were substituted for milk 
diet, the excretion during those six days varying between 
§00 and 600 grs. 

The urea was estimated with Squibb's apparatus, the 
correctness of which was checked by an experiment with 
healthy urine of a subject on a highly nitrogenous diet. 

Temperature. — The only point calling for any remark is 
that at 6 p-m. on the day of delivery patient's temperature 
ran up to 101° with a slight rigor ; as bougies had been in for 



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PREGNANCY AND LABOUR WITH BRIGHT^S DISEA8K. 27 

several days septic absorption was feared. Two hours 
after labour the temperature rose to 1 03° ; but it sank to 
subnormal in a few hours, and there was no further 
rise. 

The highest temperature during the puerperium was 
99-2°. 

These two cases illustrate a point of minor importance, 
viz. the occasional uncertainty and slowness of the method 
of inducing premature labour here adopted, viz. the intro- 
duction of a bougie between the membranes and the uterine 
wall; and the first case shows that even Barnes' dilating 
bags cannot be relied on to provoke effective labour 
pains. 

Cabb 4. First pregnancy ; symptoms beginning towards 
end of seventh month ; no retinitis ; urine containing two^ 
thirds albumen and casts ; labour induced at end of eighth 
month ; increase of albuminuria during labour ; progressive 
diminution during lying-in; no marked deficiency of urea 
elimination ; slight polyuria before delivery ; diuresis 
folloxoing delivery ; child living ; piece of placenta retained 
and removed on the ninth day ; good health eleven months 
afterwards. — (For the notes of this and the next case, and 
the analysis of the urine, I have to thank Dr. H. D. Levick, 
house physician to the hospital.) Mrs. M — , aged 28, 
admitted into the General Lying-in Hospital September 1st, 
1891, under the care of Dr. Cullingworth, by whom my 
attention was called to this and the next case, and whom 
I have to thank for permission to publish them. 

Previous history. — Never had scarlet fever. Commenced 
to menstruate at fifteen ; was regular until she married, 
except that when nineteen she saw nothing for four 
months, and was paler than usual; has always been 
weakly. Married eleven months ago, last menstrual 
period ending on January 3rd, 1891. Suffered from 
morning sickness and dyspepsia during the first three 
months of pregnancy ; after first three months was quite 
well until six weeks ago, when legs began to swell. Three 



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28 PREQNANCY AND LABOUR WITH BKIGHT's DISEASE. 

weeks ago noticed swelling of eyelids ; one week before 
admission that of legs increased considerably and gave 
her pain. No headache nor sickness except after taking 
castor oil the night before admission. No nausea, no 
dizziness, no pain in chest, and no dimness of sight com- 
plained of before admission. Consulted a doctor on 
account of the excessive swelling of legs, who examined 
her urine, found a large quantity of albumen, and advised 
her to come to the hospital. 

On admission, — Patient was very anaemic, but fairly 
well nourished. Hearths apex-beat half an inch outside 
nipple line in fifth intercostal space. Dulness commences 
above at lower border of third left costal cartilage.; the 
dulness of the right side of the heart extends half an inch 
beyond left edge of sternum. Heart sounds normal, 
except for heaving and prolonged first sound. Arteries 
rather tense, slightly thickened. Lungs : nothing ab- 
normal detected. Breasts small, nipples ill-developed 
and wanting in pigment. Abdomen : lower part oedema- 
tous; greatest girth 37 inches. Foetus in first position. 
Foetal heart heard to left and below umbilicus. Extreme 
oedema of feet, legs, and thighs, the right leg being more 
oedematous than the left one. QEdema of vulva not marked. 
Face oedematous, especially eyelids. Eyes : fundi, nothing 
abnormal detected. Urine contains two-thirds albumen ; 
quantity passed stated to be less than that passed three 
months previously. 

September 3rd, 8.30 p.m. — Per vaginam, vertex in cavity 
of pelvis, cervix thinned, admits one finger easily through 
internal os. 

The membranes were separated for one inch round 
internal os. A bougie was then passed about 9 inches 
between uterine wall and membranes. 

4th, 4 a.m. — ^Pains commenced; infrequent and irre- 
gular, described as aching. 

6 a.m. — Regular pains every five minutes. 12 noon. — 
Pains every three minutes. Os admits two fingers ; mem- 
branes bulge. Vomited four times this morning. 



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80 PBEONANCT AND LABOUR WITH BKIGHt's DISEASE. 

9 p.m. — ^Natural delivery. Child living, weight 4 lbs. 
1 5 oz., male. 

5th. — Slept well ; slight headache this morning. (Edema 
of legs decreased. Eyelids and face rather more swollen 
than yesterday morning, but not so much as on admission. 

7th. — Unable to sleep last night until Pot. Brom. gr. xxi 
was administered. No headache. No vomiting. 

9th. — Slight oedema of ankles only remaining. Many 
linese albicantes on right calf. A few on right thigh and 
left calf. 

10th. — Complains of pain in right lumbar region. Right 
kidney can be easily felt between the hands. (Edema of 
ankles slight. 

13th. — Last two days discharge offensive, thick, and 
brown. Uterine cavity explored, large mass of firmly adhe- 
rent tissue found. Chloroform administered and mass re- 
moved. Mass was brought away as one large piece measur- 
ing 2 inches by 1 J inches, a smaller piece 1 inch by J inch, 
and several fragments. These pieces looked like placental 
tissue. A small part was slightly offensive. Intra- 
uterine douche. Temperature rose to 101*8^ after manipu- 
lation. 

14th. — ^Temp. 99'4^. Discharge not offensive. 

15th, p.m. — Rise of temperature to 104°, accompanied 
by a rigor ; vomited once. Bowels were well open, and 
two and a half hours after rise of temperature and rigor, 
temperature had fallen to 101*8°. Pulse very weak, 156. 
Patient looks ill. 

16th. — Temp. 103*6°. Chloroform was administered ; 
uterine cavity was explored again, and some clots, shreds, 
and hard masses of placental-like tissue were removed by 
exploring finger. Intra-uterine douche of Tr. lodi 5J ad 
Oj. at Temp, of 110° F. Vomited after the chloroform, 
looks very white and ill. Temperature rose to 104° after 
removal of tissue from cavity of uterus. 

17th, p.m.— Temp. 99*2°. Pulse 112. Looks and 
feels much better. Slept well. Discharge not offensive, 
slight. 



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PftBONANCY AND LABOUR WITH BKIOHT's DISEASE. 81 

18tli, a.m. — Temp, rose to 105*4° with a rigor. Tepid 
sponging. Intra-uterine douche of Tr. lodi 33 ad Oj, 
110° P. P.m., temp. 100°. Pulse 110. Some sleep. 
Patient has been taking nourishment well. 

20th. — ^Temperature down to 99*4°. From this time the 
patient made a slow but uninterrupted recovery, and went 
out convalescent on October 1st. 

Urine : Quantity. — Before delivery the amount of urine 
collected was slightly above what is usually regarded as the 
normal quantity ; it averaged 52 oz. per day. After deli- 
very there was diuresis, 70 oz. being collected on the 
second day, and the maximum, 100 oz., on the third day. 
Then the daily quantities of urine began to decrease,, 
and after the first week the daily amount collected did 
not exceed the usual amount; it fluctuated between 20 

I and 40 oz. 

j Specific gravity, — This does not call for special remark. 

I Its variations were, on the whole, inversely as the quantity. 

Albumen. — The amount of albumen varied. The urine 
contained about two-fifths of its bulk of albumen when 
admitted. In the two days following admission it dimin- 
ished under the influence of rest and milk diet. It reached its 
maximum, three-quarters, just before delivery — a change 
most easily accounted for by the increased abdominal pres- 
sure due to the straining with the pains. After delivery 
it fell to what it had been before, and during the lying-in 
it showed a further slight diminution, so that when the 
patient was discharged the urine only contained about 
one-tenth of albumen. I have no notes as to the relative 
amounts of paraglobulin and serum-albumen. 

Urea. — ^The urine of each period of twenty-four hours 
was mixed together, and the percentage of urea in it esti- 
mated with Squibb^s apparatus. The patient was instructed 
to allow the catheter to be passed when an action of the 
bowels was expected, and to save all urine that she passed 
at other times. 

I In spite of these precautions doubtless some urine 

escaped collection, and the quantities shown are therefore 



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32 PBBQNANCY AND LABOUR WITH BBIQHT^S DI8KA8B. 

incorrect in being below the true amount. On some days, 
from causes needless toparticularise, the collection or 
examination was known to be imperfect, and these days 
are omitted. The chart shows very wide variations 
between the amounts of urea eliminated on different days, 
the causes of which I cannot explain. I think that the 
figures are correct, because I have confidence in the care- 
fulness with which Mr. Levick made them, and because simi- 
lar variations have been observed in other cases. Taking 
them as a whole, the average was 279 grs. per day before 
delivery, and 280 grs. per day after delivery, until the 
time at which the patient began to take flesh food. The 
observations after the date of meat diet are not numerous 
enough to be worth averaging. 

There was thus here no such diminution in the amount of 
urea as has been observed in eclampsia cases. Taking 
into consideration the patient's diet, the quantity can hardly 
be considered to have been at all below the normal. 

Deposit, — Throughout the whole of the patient's stay in 
hospital granular casts were present as a deposit, together 
with urates, pus corpuscles, and once a little blood. 

Reaction, — This was twice slightly alkaline, once neutral, 
on all other occasions acid. 

March 30th, 1892. — Patient attended at the hospital. 
Feels and looks well except that she is anaemic. Has been 
taking iron since discharge. No oedema. Urine contains 
one-sixth albumen. 

April 7th. — Dr. Ashton Warner (Kensington) writes 
that he has several times found no albumen. 

August 9th. — Is five months pregnant ; no albumen. 

Case 5. Second pregnancy ; symptoms three weeks before 
admission; vomiting; diarrhcea; oedema; labour at term; 
lingering first stage a/icelerated by bougie ; child living ; 
urine containing casts and one-fourth albumen; increase 
of albuminuria to one-half during labour; diuresis after 
delivery ; diminution of albuminuria during lying-in ; no 
marked diminution in urea excretion; good health and 



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PBKGNANCT AND LABOUR WITH BBIOHt's DISEASE. 83 

freedom from albuminuria six months afterwards, — Mrs. J., 
»t. 23, admitted into the General Lying-in Hospital October 
20th, 1891. 

Never had scarlet fever or any illness except her first 
confinement, which was natural. Last menstruation ended 
December 25th, 1890, and fourteen days afterwards morning 
sickness commenced, and continued until she quickened, 
after which it occurred occasionally up to fourteen days 
before admission, when it became persistent, occurring five 
or six times a day ; during last fourteen days two loose 
motions daily. During last three weeks has only passed 
about half her average quantity of urine. 

On the 17th of October legs became swollen, more so 
than on admission. 

On the morning of admission, after retching noticed 
for the first time that her eyelids were swollen. A doctor 
sent her to the General Lying-in Hospital. Urine one- 
third albumen. 

21st. — Patient is pale, but fairly well nourished, with 
swelling of thighs, legs, abdomen, and face. Slept well 
last night, no labour pains since admission. Complains of 
pain over the eyes. 

22nd. — Still pain over eyes, but has had some sleep. 
No vomiting. No labour pains. Bowels opened three 
times. (Edema of legs not so tense ; right calf measures 
15 inches, and left 13} inches ; oedema of other parts about 
the same. Heart : impulse in nipple line in fifth space ; 
dolness commences above the third costal cartilage on the 
right, extends 1 inch to right of left edge of sternum. 
First sound not clear, but no murmur. Radial pulse 
tense, but vessel wall not thick. Lungs : a few rhonchi 
over left lung. Slight cough two days. 

23rd. — Severe headache. Vomited four times. Bowels 
not opened. Towards evening headache less, and patient 
slept. Some labour pains. 

24th. — ^Waked up occasionally by pains. On two 
attempts to sit up, nausea followed by vomiting. No 
headache. Pains every fifteen minutes. Complained of 

VOL. xxxvi. 3 



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34 PBBaKANCT AND LABOUR WITH BBTOHT's DISEABB. 

a sensation passing from abdomen over chest, taking her 
breath away ; this occurred about every two hours 
yesterday afternoon. Eyelids and legs rather more 
swollen, right calf measuring 15^ inches, left one 14 
inches. To have chloral, 15 gr., every six hours; 
p.m., bowels opened by enema. 

25th. — Slept well, waked up during night with pains. 
This morning no headache, vomited once after chloral, 
no labour pains now, Os soft, ragged from old lacera- 
tions ; size of a two-shilling piece. Since admission 
patient has been on full diet with beef-tea instead of 
meat. 

26th. — Slept well. No labour pains ; no vomiting ; 
slight headache. Shooting pain in chest for fifteen 
minutes this morning. (Edema: right calf measures 
15i inches, left one 14^ inches. Os size of half-a-crown, 
soft and dilatable. Membranes separated with finger all 
round. Diagonal conjugates 4f inches. Foetus in first 
position. Foetal heart heard. 

27th. — Slight pains during night, but a good night's 
sleep. Slight headache. Bowels open by enema. No 
vomiting, but nausea. Complains of a sensation, described 
as if a cord were dragged from abdomen through chest and 
neck into head. Since admission has never been able to 
sit up without feeling giddy. 11 a.m., flexible bougie 
passed up between uterine wall and membranes. 8 p.m., 
pains every twenty minutes. 12 midnight, os size of 
four-shilling piece ; pains frequent. 

28th, 3 a.m. — Pains became strong. 5.5 a.m., spon- 
taneous rupture of membranes at full dilatation. 
5.20 a.m., natural delivery of a living male child, 20i 
inches long, and weighing 7 lbs. 

29th. — Slept well ; no vomiting ; no headache ; no 
diarrhoea. (Edema of legs less; right calf measures 
15 inches, left one 13^ inches. Swelling of face about the 
same. 

31st. — (Edema decreasing, right calf measures 13 inches, 
left one 12J inches. 



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86 PBBQNANCT AND LABOUR WITH BBIQHT^S DISEASE. 

November 1st. — Rhonchi over both lungs. To take 
following mixture ; 

Tr. Campb. Co., TT\,xv. 
Oxymel ScillSt TT\,xxx« 
Infus. Cascarillse, ^, 6tU boris, 

2nd. — CEdema very slight. To have meat. 

5th. — ^Vomited last night after cough medicine. During 
night temperature rose steadily, and to-day is 100'4°. No 
vomiting or nausea this morning. Bowels not opened 
for two days, last opened by house mixture and enema. 

6th, — This morning Pil Rhei Co., gr. x, were given. 
This afternoon patient vomited twice. Bowels were opened 
five times. 6 p.m., splitting headache ; shivering. 

7th. — ^No headache, vomiting, or diarrhoea. 

8th. — To have chicken or chop. 

11th. — Discharged free from oedema, vomiting, or 
diarrhoea. 

25th. — Eyes examined ; brown patch on outer side of 
left optic disc. Vessels passing over it curved. 

Urine, — The course of the urinary excretion bears a 
close resemblance to that observed in other cases that I 
have reported. 

Quantity. — Before delivery somewhat less than the 
average of health, viz.\24i ounces per day. After 
delivery diuresis, the maximum, 100 ounces, being reached 
on the fifth day. After this a drop to near the old rate, 
viz. between 20 and 40 ounces per day. 

Albumen. — ^Before delivery the amount of albumen was 
about a quarter. It was increased to about half the bulk 
of the urine during labour, and within two days after 
delivery had become less than before labour. There was 
a temporary increase in the second week of the lying-in, 
but when the patient was discharged there was only about 
one-twentieth of albumen. The relative proportions of 
serum-albumen and paraglobulin were not ascertained. 

Specific gravity. — ^Before labour the specific gravity 
was usually near 1020. During the diuresis after delivery 



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PBEGNANCT AND LABOUB WITH BRIOHT's DISEASE. 37 

the specific gravity decreased, going down to as low as 
1007, but it increased again as the quantity of urine 
became reduced. 

Urea. — The curve showing the percentage of urea 
roughly corresponds in its elevations and depressions to 
that of the specific gravity of the urine. The absolute 
quantity of urea was, on admission, not far from the 
average of health, 335 grains per day. During the three 
days preceding delivery it fell, and continued to do so 
after delivery till the fourth day, when it began to rise. 
After this the curve shows great variations, which I 
cannot account for ; but the average, after the fourth day, 
was 254*5 grains per diem. The variations are partly 
accounted for by diet. As I could only state from the 
notes what was ordered for the patient, and not what she 
took, no useful result would follow from a detailed con- 
sideration of the changes in diet and accompanying 
changes in the urine. 

Deposit. — The urine throughout gave a deposit of 
granular casts, beside, after delivery, uric acid crystals, 
pus, and blood-corpuscles. 

April 6th, 1892. — Patient attended at hospital. Is 
somewhat anaemic, but considers herself quite well. Urine 
contains no albumen. 

Case 6. First pregnancy; symptoms a week before 
admission ; cedema, tveakness, short breath, cardiac hyper^ 
trophy ; urine containing one-third albumen ; labour 
induced at eight months ; child living ; no Jits ; no great 
deficiency of urea elimination; diuresis, increased urea 
elimination, and diminution of albuminuria following de- 
livery ; good health a year and eight months afterwards, — 
Mrs. B — , aet. 35, admitted into the General Lying-in 
Hospital December 8th, 1891, under the care of Dr. 
Cullingworth. For the notes of this case and the 
analysis of the urine I am indebted to Dr. A. E. Giles, 
House Physician to the hospital ; and I have to thank 



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38 PBEONANCT AND LABOUB WITH BBIGHT^S DISEASE. 

Dr. CuUingwortli for permission to observe and publist 
the case. 

Patient's mother and father died from dropsy ; a sister 
and a brother died from Bright's disease. Patient had 
had measles and scarlet fever in childhood. At eighteen 
had rhenmatic fever. Visited Egypt five years ago, 
and had attacks of low fever. First menstruated at 
seventeen, was regular but scanty till pregnancy. Last 
menstruated in March (exact date forgotten). During 
pregnancy had little sickness, but suffered much from 
constipation, thirst, and sleeplessness. For a week before 
admission had felt weak and ''out of sorts,'' and been 
troubled with frequent micturition and with shortness of 
breath. The present was her first pregnancy. 

On admission her legs were cedematous ; she said her 
eyelids had been puffy. There was evidence of cardiac 
hypertrophy, and a marked thrill at the apex, but no 
murmur. There was no dilatation of the cervix. The 
size of the uterus corresponded to eight months' preg- 
nancy. 

December 10th. — ^Bougie introduced at 12.45 p.m. 
Pains began at 8 p.m. Vomited at 10 p.m., after which 
pains passed off, and next morning the bougie was found 
in the vagina. A douche of Condy's fluid was given 
twice daily after putting in the bougie. 

11th. — 9.30 p.m., ergot 3ss given. 11.30 p.m., ergot 
5S8 and chloral 9j. 

12th. — Soon after the douche the pains returned. As 
the OS dilated slowly the patient was given chloral gr. xx 
at 4 p.m. and at 8.15 p.m. At 10.45 p.m. membranes 
ruptured spontaneously. 1 1 .30 p.m., os fully dilated. 

13th. — 1.30 a.m., head low down, but pains feeble. 
Delivery finished with forceps. Placenta expressed, 1.50. 
Uterine contraction not good; 25 ounces of blood lost. 
Ergotine, 3 J grains, given hypodermically. Child, 
female, living ; weight, 4 lbs. 12 ounces. 
14th. — Diarrhoea and vomiting. 
15th. — ^Vomiting better ; diarrhoea continues. 



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40 PREQMANCT AND LABOUB WITH BRIGHT'b DISEASE, 

16tli, — ^Diarrhoea better. 

20th. — Diarrhoea ceased. 

30th. — ^Discharged. 

August, 1893. — Patient thinks herself quite well. Has 
no swelling of legs. Has had a miscarriage since con- 
finement. 

The temperature never exceeded 99°. 

Urine : Quantity. — ^The urine was drawn off twice a 
day by catheter, and the patient was instructed to avoid 
if possible emptying the bladder at other times. Pro- 
bably, however, some did escape when the bowels acted, 
and as there was diarrhoea I think a good deal may have 
been lost, and therefore that the quantities recorded err 
more than in most of the cases I have published ; but all 
the error is in the direction of the figures being too low. 
This case shows an amount collected below the average of 
health, but the same diuresis after delivery as the others, 
the curve reaching its maximum on the third day. But 
on this day the quanity of urine was only 42 ounces. 
After this day the daily average collected was 25^ ounces. 

Specific gravity. — This varied from 1009 to 1021. Its 
average was 1015. Its fluctuations were, broadly speak- 
ing, inversely as the quantity of the urine. 

Urea, — The urea curve shows a rough correspondence 
to that of the quantity of the urine. On the day before 
delivery the amount estimated was 240 grains. After 
delivery there was an even larger increase in the urea 
than in the urine, on the third day as much as 700 grains 
being estimated. From the fourth day onwards the 
average daily amount was 279 grains, and the fluctuations 
above and below this amount were not great. The per- 
centage of urea was never below 2, and on the second and 
third days after delivery was as high as 3'55. From the 
fourth day onward it averaged 2*6. 

Sugar, — The urine at no time contained any sugar. 

Deposit, — On most days there was a deposit of urates. 

Albumen, — The urine collected after delivery contained 
about one-third of its bulk of albumen. It then gradually 



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PBEONANCT AND LABOUB WITH BBIGHT^S DISKASE. 41 

diminished during the week following delivery, and after 
this date was reduced to a small trace. 

In this and the foregoing papers I have related eleven 
cases of pregnancy with albuminuria, but without eclampsia. 
I shall now summarise the facts they exemplify, and com- 
pare them with the cases of eclampsia which I have 
epitomised in a paper published in vol, xxxiii of the 
Society^s * Transactions.' 

For convenience I shall refer to them by consecutive 
numbers as follows : 

Paper 1. — ' Transactions,* vol. xxix. Case 1 — 1. 
Paper 2. — „ vol. xxxii, „ 1 — 2. 



99 99 




99 


» 


2—3 


99 99 




99 


» 


3—4 


99 99 




99 


» 


4^5 


Present communication, 


Case 1—6. 






99 99 




2—7. 






99 99 




3—8. 






99 99 




^^9. 






99 99 




5—10. 






99 99 




ft— 11. 







As to parity : in two it was the first pregnancy, in 
three the second, in one the third, in one the fifth, in one 
the sixth, in one the tenth, in one the sixteenth, and in 
one no history was attainable. 

In this point there is a difference between the cases of 
eclampsia and those of albuminuria without eclampsia. 
The pregnancy was the first in seven out of twelve cases 
of eclampsia, but only in two out of ten cases of albumi- 
nuria without eclampsia. 

The average age of the eclampsia patients was twenty- 
five ; that of the cases of albuminuria without eclampsia 
29-6. 

As to the effect on the child : out of eleven cases, in 
one pregnancy was terminated at five months. In one 
the child died in utero. In one the child died during 



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42 PBfiONANCT AND LABOUR WITH BRIGHT^S DISEASE. 

delivery from pressure on the cord. In the other cases 
the children were bom alive. 

We see here a difference between the cases of eclampsia 
and those of albuminuria without eclampsia. Among the 
eclampsia cases four children out of ten died in utero ; 
among the cases of albuminuria without eclampsia only 
one out of ten. 

Urine : Quantity. — Out of the eleven cases, in four (3, 5, 
10, and 11) the, quantity of urine passed daily before 
delivery was below the average of health ; but in two of 
these (5 and 11) the collection was so imperfect that the 
apparent diminution was largely due to this cause. Of 
the other two, one (3) was a case of dropsy of the amnion, 
in which, therefore, the tension within the abdomen was 
greater than usual. In the other (10) I have unfortu- 
nately no note of the size of the belly, but the patient had 
reached full term, the child weighed 7 lbs., and there was 
oedema of the legs so great as to make the skin tense ; so 
that it may be inferred that here there was considerable 
tension within the belly. In these cases, although less 
urine was passed than usual, yet there was nothing like 
the diminution observed during eclampsia. In the case 
of hydramnios (3) the daily amount of urine before 
delivery averaged 25 ounces, and in the case with great 
oedema of legs (10) it averaged 24i ounces. In all the 
other cases the quantity of urine was more or less above 
the average. The largest increase was in Case 7, in which 
the average daily amount before delivery was 75 ounces. 
This patient died about a month after delivery. It is 
noteworthy that in the only one of the eclampsia cases that 
passed into chronic Bright's disease there was polyuria. 

In two patients it was not possible to ascertain the daily 
amount of urine after delivery. These two unfortunately 
were fatal, one seven days, the other a month after 
delivery. In each of the other cases delivery was followed 
by increased diuresis. The diuresis was greatest in the 
patient whose urine had been diminished in quantity before 
delivery. In the hydramnios case (3) it rose to 118 



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PRSQNANCT AND LAB0C7B WITH BBIOHT's DISEASE. 43 

ounces in the twenty-four hours ; and in the patient at 
term with swollen legs (10) it reached 100 ounces. 
Further, in the patients who got well, that is, who left 
the hospital free from albuminuria (2, 3, 9, .10, 11), the 
increase in the amount of urine after delivery was greater 
than in those (1, 4, 6, 8) in whom the albuminuria per- 
sisted. But in this point the difference is not so striking 
that I need trouble the Society with details, and I think 
it less important than the variations of the urea excretion, 
of which I shall presently speak. 

Albumen. — First, as to quantity of albumen and its 
variation. Among these eleven cases of albuminuria 
without eclampsia before delivery, in two the urine is 
said to have been solid on boiling (2, 3). In five it con- 
tained half or more of its bulk of albumen, but did not 
become solid (1, 5, 7, 8, 9). In four it contained less than 
half its bulk (4, 6, 10, 11). 

Comparing these cases with those of eclampsia, I find 
that among the eclampsia cases, in every one the urine 
was at some time solid with albumen. In eight the urine was 
solid with albumen when the patient was admitted. In four 
there was half or less albumen when the patient was ad- 
mitted, but the urine becamo solid or nearly so after the fits. 

In this a difference is apparent between the cases of 
albuminuria without eclampsia, and those of eclampsia, 
viz. that in the latter the urine contains much more 
albumen. In three of the latter the amount of albumen 
was increased while the patient was having fits. This 
may suggest that the difference between the two sets of 
cases may be simply because the fits produce increased 
albuminuria. But this is not the sole explanation. First, 
in two of the cases of albuminuria without eclampsia, 
although there were no fits, the urine was solid with 
albumen. Second, in two cases in which the fits came on 
after delivery (' Trans.,' vol. xxxiii. Cases 1 and 5) the 
amount of albumen diminished although the fits continued 
to occur. Third, the amount of albumen does not show a 
variation concomitant with the number .of the fits and the 



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u 

length of time during which they have persisted. Thus in 
Case 2, ' Trans./ vol. xxxii, the patient had had five fits 
in four hours, and the urine only contained half its bulk 
of albumen. In Case 2, ' Trans./ vol. xxxiii, the patient 
had had five fits in three hours, and the urine only con- 
tained two-fifths of its bulk of albumen ; while in Case 5, 
' Trans.,' vol. xxxiii, the urine drawn off immediately after 
the first fit was found solid with albumen. 

The relative amounts of serum-albumen and paraglo- 
bulin were unfortunately only ascertained in four cases. 
In two (5 and 8) the albumen was almost entirely serum- 
albumen. One of these died, and in the other the disease 
persisted. In one (1) about one-sixth of the precipitate 
was paraglobulin. In this case the disease persisted. In 
one case (3) about half the albuminous precipitate was 
paraglobulin. This was the case of dropsy of the 
amnion in which there was great diminution in the 
quantity of urine before delivery, and copious diuresis and 
increase in the urea excretion after delivery. I regret 
that this point was lost sight of in the other cases. These 
four cases support the view that " paraglobulin is in excess 
when the transudation is due to altered pressure in the 
vessels, while serum-albumen is found in cases in which 
the kidney structure is diseased.*'* 

Seeing this difference exists, the question suggests itself. 
Does the presence of a large amount of albumen in the 
urine modify the prognosis ? 

We have ten patients in whom the urine was solid. 
Of these, eight had eclampsia, two died, six recovered 
completely. In two there were no fits ; both these com- 
pletely recovered. 

We have five cases of albuminuria without eclampsia 
whose urine contained half or more of its bulk of albumen. 
Of these five, two died, one recovered completely, in two 
the renal disease persisted. 

We have eight patients in whom the urine contained 
less than half its bulk of albumen. Of these, four had 
• •TransactioDt/ vol. xxix, p. 548. 



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PBBQNANCT AND LABOUR WITH BBIOHT's DISEASE. 45 

eclampsia; two died, one recovered, and in one the renal 
disease persisted. In four there were no fits. Of these 
two completely recovered, and in two the renal disease 
persisted. 

In short, urine solid : two deaths, eight recoveries. 
Urinenot solid: four deaths, four recoveries, five persistence 
of disease. Grouping them differently, more than half 
albumen : fifteen cases, four deaths, nine recoveries, two 
persistence ; less than half albumen : eight cases, two 
deaths, three recoveries, three persistence. 

It would seem, therefore, that a large amount of albu- 
men goes with slightly greater immediate danger, especially 
if fits are present, but with less tendency to persistence of 
the renal disease. 

The difference between the two sets of cases that has 
been just pointed out suggests a further question. Is 
there any difference in the mode of onset ? 

In the eight cases of eclampsia with more than half 
albumen the duration of symptoms before the fits was as 
follows : — In one, a few hours (3) ; in one, twelve hours (1) ; 
in one, thirty-six hours (7) ; in two, two days (5, 11) ; in one, 
three weeks (10). Of these, the patient (10) who had pre- 
monitory symptoms for three weeks, and one (11) of those 
who had them for two days, died ; the others, whose pre- 
monitory symptoms were of less duration, recovered. 

In the four cases of eclampsia in which the urine con- 
tained half or less of its bulk of albumen the following was 
the duration of symptoms before the fits :— In two, a week 
(6, 9); in two, three weeks (4, 8). The two former of 
these died; of the latter, one recovered, in the other 
the albuminuria persisted. It will be seen that among 
the eclampsia cases the premonitory symptoms had been 
present longer in those that had the less albumen ; that 
in those in which the albumen was solid with albumen 
the symptoms came on more rapidly. 

In the eleven cases of albuminuria without eclampsia 
the duration of premonitory symptoms was as follows : — 
In the two cases in which the urine was solid with albumen. 



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46 PBEGNANOT AND LABOUB WITH BBIQHT's DISEASE. 

in one, a month (2) ; in two, indefinite, perhaps four months 
(3). Both these patients recovered. 

In the five cases in which the urine contained half its 
bulk or more of albumen, but was not solid, in one, a 
month (9) ; in one, six weeks (1) ; in one, indefinite (5) ; 
in one, twelve months (7) ; in one, four years (8). Of 
these, the first, in which the symptoms were of the shortest 
duration (9), recovered. Of the others, two (5, 7) died, 
and in two (1, 8) the albuminuria persisted. 

In the four cases in which the urine contained less than 
half its bulk of albumen, in one, a week (11) ; in one, 
three weeks (10) ; in one, a month (4) ; in one, sixteen 
months (6), In three of these the disease persisted; in 
one only (10) did recovery take place. Comparing these 
cases with those of eclampsia, one broad fact is seen, viz., 
that in them the symptoms had lasted longer than in those 
who had fits. In other words, the disease producing 
eclampsia was a more acute morbid process than that pre- 
sent in the cases of albuminuria without eclampsia. 

Urea. — In every one of the cases of albuminuria with- 
out eclampsia the daily amount of the urea excreted in the 
urine was below the average of health. There was a differ- 
ence in this respect between the cases that recovered and 
those in which the albuminuria persisted. The deficiency 
was greater in the cases that did not lose the albuminuria. 
Averages will show this better than the records of indivi- 
dual cases. The average daily excretion of urea in those 
that got well was 270 grains ; of those in which the dis- 
ease persisted, 215 grains. Among these latter was one 
who two years afterwards was apparently in as good health 
as at the time of her confinement, although her urine still 
contained half its bulk of albumen. In this case the renal 
function cannot have been much impaired, and her daily 
urea excretion before the confinement was 280 grains. If 
her case be removed from the list of those in which kidney 
disease persisted, their average daily excretion of urea is 
brought down to 198 grains. 

In every one of the cases of albuminuria without 



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PBBONANCY AND LABOUR WITH BBIQHt'b DISEASE. 47 

eclampsia there was an increase of the urea excretion after 
dehvery. This increase took place, as th6 charts will 
show, very quickly after delivery, before the patients 
had left off the liquid diet usual during labour and 
the first days of the lying-in period. If we compare 
the cases which recovered with those in which the disease 
persisted, we find that in those which recovered the in- 
crease in the lying-in period was greater than the increase 
in those in whom the renal disease persisted. The quantity 
of urea excreted daily varies, from causes which in individual 
cases cannot always be identified. I shall show this 
difference by quoting the maximum and minimum excre- 
tion in a day during the lying-in. I give the figures in 
each case, and the averages. 

I. Oases that recovered. 









Before delivery. 

Average 
daily excretion. 

215 grains. 

282 „ 


After delivery. 


Case No. 
2 
3 


Maxiinam 
daily excretion. 

606 grains. 

800 „ 




Minimam 
dAily excretion. 

262 grains. 

260 „ 


9 






279 „ 


475 .. 




100 „ 


10 






335 „ 


370 „ 




135 „ 


11 240 „ 700 „ 300 „ 

Average of Average Average 

the whole 270 „ maximum 590 „ minimum 211 „ 




II. 


Cases in which the renal disease persisted. 


1 

4 






245 grains. 
156 „ 


240 grains. 
360 ,. 




112 grains. 
160 „ 


6 






240 „ 


295 „ 




104 ,. 


8 






280 „ 


620 „ 




390 „ 


7 152-5 ., 678 ,. Ill ,. 

Average of Average Average 

the whole 215 „ maximum 429 „ minimum 173 „ 



Deducting Case 8, who two years afterwards seemed in 
unimpaired health although the albuminuria persisted, 
we have — ^Average of the whole, 198 grains; average 
maximum, 868 grains ; average minimum, 122 grains. 

Deposits. — In two cases I have no record whether casts 



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48 PBEONANCT AND LABOUR WITH BRIOHX's DISEASE. 

were present or not. In all the others casts were 
present. 

Retinitis. — Albuminuric retinitis was present in three 
(1, 4, 6). In all these patients the albuminuria persisted. 
Two of these died within a few months, the other I have 
been unable to trace. In one case the eyes were not 
examined. In one there was a doubtful retinal haemor- 
rhage. This patient recovered. In the cases of eclampsia 
with retinitis one died, and in the other the disease per- 
sisted. Retinitis thus seems to be a sign of bad prognos- 
tic import. 

Summary, — ^A comparison of these cases with one another 
and with the cases of puerperal eclampsia that I have 
published in former papers points to this general conclusion. 

There are at least two kinds of renal disease of which a 
pregnant woman may be the subject, and to which preg- 
nant women seem specially liable. One of these is a 
very acute disease, coining on either without any premoni- 
tory symptoms or with premonitory symptoms of very 
short duration, i. e. usually measurable by days. It 
attacks chiefly primigravidae. It often causes intra- 
uterine death of the child. It is attended with extreme 
diminution in the quantity of urine, and the small 
quantity of urine passed is greatly deficient in urea, but 
contains enough albumen to make it solid in boiling. 
This is the disease which is accompanied with rapidly 
recurring fits. If the disease runs a favourable course the 
fits cease, then the urine increases in amount, and the per- 
centage of urea in it rises. If the excretion of urea is not 
re-established the case quickly ends fatally. Such cases 
seldom if ever pass into chronic Bright' s disease. 

The other is a disease which attacks older subjects, 
chiefly those who have had children before. Its premoni- 
tory symptoms are gradual and slow in onset, i. e. usually 
measurable by weeks or months. It less often leads to 
intra-uterine death of the child. It is generally accom- 
panied with increase in the quantity of urine, with copious 
loss of albumen, but not so much in proportion to the 



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FBB0NAKC7 AND LABOUB WITH BBIOHT^S DISEASE. 49 

urine as in the more acute disease ; and with diminution 
in the amount of nrea^ but not nearly so great a diminution 
las in the acute disease. In these patients delivery is 
followed by temporarily increased diuresis^ and by increase 
in the excretion of urea. When this increase is consider- 
able the patient usually gets well^ and the albuminuria 
ceases. When the increase is only slight the albuminuria 
persists^ and the case becomes one of chronic Bright's 
disease. This form of disease is sometimes attended with 
fits, but generally not. The presence of albuminuric 
retinitis affects prognosis unfavourably. When the pres- 
sure within the abdomen is greater than usual the 
amount of urine may be diminished ; but in such cases the 
diuresis and the augmented excretion of urea after delivery 
are proportionately greater. In the acute disease which 
causes eclampsia, and in the chronic disease when it is 
associated with excessive intra-abdomimal pressure, much 
of the albumen is paraglobulin. The cases in which the 
albumen is mainly serum-albumen generally either die or 
pass into chronic Bright^s disease. 



pa] 
for 



Dr. CuLLiNowoBTH thanked the President not only for the 
bper just read, but for the series of papers of which this 
'ormed the conclusion, the whole series having been of the 
highest scientific value. Great difficulties surrounded the sub- 
jects of puerperal albuminuria and puerperal eclampsia, and 
numberless theories had been propounded, all of which failed 
more or less to adequately explain the phenomena. What they 
now wanted was not more theories, but an unbiassed and 
minutely accurate clinical record of a series of, cases sufficiently 
extensive to embrace most of the varieties, and to enable some 
general conclusions to be drawn. Dr. Hermfm's papers pro- 
vided such a record, and no fature writer on these subjects 
could afford to overlook the collection of observations which he 
had with great labour got together, and had now placed at the 
disposal of the profession. It was customary for the President 
to convey to the readers of papers the thanks of the Society for 
their communications. The President obviously could not be 
expected to do this on the present occasion. He (Dr. Culling- 
worth) therefore desired to move a hearty vote of thanks to the 
President, and if that motion were seconded he would ask Dr. 
VOL. xxxvi. 4 



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50 FRSGNANCT AND LABOUR WITH BRIOHT's DISEASE. 

Watt Black, the only ex-president in the room, to be good 
enough to put the i*e8olution to the meeting. 

Dr. Giles said he had much pleasure in seconding Dr. 
Cullingworth's motion. He could endorse all that Dr. Culling- 
worth had said in appreciation of this paper and the others of 
the same series wbicn Dr. Herman had previously given them. 
To him it seemed that the most notable feature of these papers 
was the valuable analysis of facts which they contained. A 
good many facts had been previously collected, but from want 
of clear-sighted analysis the subject was still obscure. At the 
same time he fully appreciated the care and thoroughness with 
which Dr. Herman's facts had been obtained. The division 
into two classes which had been adopted in the paper was con- 
ducive to a better understanding of the relationship between 
eclampsia and albuminuria. These two classes showed a close 
parallelism with acute and chronic nephritis respectively apart 
from pregnancy. It was stated in text-books that eclampsia 
could occur without albuminuria. He had not seen a case, but 
had met with some half-dozen cases of ursBmia in which no 
albumen was found in the urine. The explanation was not 
very easy ; it was possible that in such cases the kidney struc- 
ture was too far diseased even to admit the passage of albumen 
into the tubules. But whatever the explanation, it was' pretty 
clear that the absence of albumen, whether in eclampsia or in 
uraemia, could not be interpreted as excluding kidney disease. 

Dr. Amand Bouth described two cases which he was attend- 
ing at the same time in an institution. One was five and the 
other seven months pregnant. They both had head symptoms, 
with marked albuminuria and oedema. The one five months 
pregnant had some retinal hsemorrhage, a somewhat severe 
epigastric pain, and the deposit on boiling her urine was almost 
pure serum-albumen. The woman who was seven months 
pregnant had no retinitis, no epigastric pain, and a large pro- 
portion of the deposit on boiling her unne was paraglobulin. 
The former case developed eclampsia the day after she was first 
seen, miscarried, but did well, the albumen disappearing in a 
month. The latter case had labour induced, and had no bad 
symptoms, all albumen disappearing shortly after labour. He 
asked for further information as to the significance of para- 
globulin in the urine, and as to epigastric pain, whioi he 
believed to l>e a very tinfavourable symptom. 

Dr. William Duncan thought the series of papers by the 
author on the subject under discussion of the greatest import- 
ance both to the public and the profession. He agreed with the 
author as to there being two classes of cases of renal disease 
associated with pregnancy. He thought when there was marked 
retinal disease that the prognosis was much graver than when 
such a condition was absent. He mentioned two cases of preg* 



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FBSONANCY AND LABOUR WITH BRIGHT's DISEASE. 51 

nancy associated with albuminuria in wbicli there was kidnej 
disease and well-marked albuminuric retinitis; in both he 
induced abortion, with the result that in one of the cases the 
retinal disease was much improved, but in the other the total 
blindness which existed at the time of emptying the uterus still 
continued two months later when the patient left the hospital. 
He (Dr. Duncan) thought the uterus should be at once emptied 
when there was any indication of retinal mischief. 

Dr. Peter Horrocks said his own experience coincided with 
that of Dr. Herman regarding the gravity of retinal hsemor- 
rhi^es in cases of eclampsia. He could not remember a single 
recovery when such a lesion was present. He thought the new 
facts elicited by the careful observations made would enable one 
to suggest suitable treatment in different cases. 

The President said that Dr. Bouth's cases were very inter- 
esting, and it was to be hoped that he would publish a full 
account of them. He (the author) had stated the conclu- 
sions to which his cases pointed, but the cases were too few to 
settle finally the import of the amount of paraglobulin. He did 
not think that the acute disease which produced eclampsia was 
a^ute nephritis. The onset of the fits without premonitory 
symptoms, and the recovery within thirty-six or forty-eight 
hours were quite unlike anything seen apart from pregnancy ; 
added to which was the fact that in some of the fatal cases the 
kidneys presented no morbid change that could be identified by 
the naked eye. He i^eed with Dr. Duncan that if albuminuric 
retinitis were present during pregnancy, labour should be 
induced ; but he would go f urUier, and urge the prompt termi- 
nation of pregnancy in any case in which this condition was 
complicated with unquestionable kidney disease, A pregnant 
woman with kidney disease was liable to eclampsia, and the 
probability of a temporary renal change passing into chronic 
Bright's disease was greater if the pregnancy went on ; and in 
addition Bright's disease often caused intra-uterine death of the 
child. He thought that it was desirable to restrict the applica- 
tion of the term "eclampsia" to cases of albuminuria with 
convulsions. The pathology of cases in which there was no 
albumen was quite aifferent, and he thought it would be better 
to speak of these simply as cases of '' fits " or " convulsions,'* 
not as " eclampsia." 



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52 



A NOTE ON VAGINAL SECRETION. 
By William John Gow, M.D.Lond., M.R.C.P., 

PHTSICIAV-ACCOirCHBU'B IV OHABGB OF 0UT-PATIBNT8, 8T. MABT'B HOSPITAL. 

(Received November Ist, 1893.) 

The secretions found in the vagina are derived partly 
from the mucous membrane of the cervix, partly from the 
mucous membrane of the uterine body, and partly from 
the surface of the vagina itself. Any secretion from the 
vaginal surface is found, therefore, under ordinary cir- 
cumstances, mixed with secretions from the neck and body 
of the uterus. Secretions in the vagina must be distin- 
guished from secretions of the vagina. Inasmuch ad 
doubts have been expressed as to whether the vaginal 
surface does contribute at all to the fluids found moisten- 
ing its walls, it may be worth while in the first place, 
before discussing the nature of this secretion, to offer a 
few remarks in proof that the vagina does secrete. I 
have had the opportunity of investigating the secretions 
found in the vagina in several cases in which I had pre- 
viously extirpated the uterus for malignant disease. In 
all these cases the wound in the vaginal vault had com- 
pletely healed, and the walls of the vagina appeared 
healthy and were free from cancerous infiltration. It was 
found on all occasions, when the parts were examined, 
that the vaginal surface was moist and bathed with a 
secretion which possessed a distinctly acid reaction. The 
whole surface of the vagina, lower and upper part alike, 
was moistened with this secretion. Now in these cases it 
was impossible for the fluid bathing the parts to have 



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VAGINAL 8BCESTI0N. 58 

been derived from any adventitious source, and therefore 
it must have come from the vagina itself. 

In cases of extensive prolapse, where the os externum 
lies permanently outside the vulva, it is customary to find 
the vaginal walls completely everted with the exception 
of the lowest inch of the posterior wall. It was always 
found that the walls of the pouch thus formed were 
moist, and possessed an acid reaction. In these cases also 
the fluid present must have been derived from the vaginal 
surface. From a consideration of these facts I think it 
may be asserted without fear of contradiction that the 
vagina secretes. 

The next point to consider is how this fluid is secreted, 
and in this connection it will be necessary to briefly 
allude to some of the arguments that have been brought 
forward, on theoretical grounds, to prove that the vagina 
does not secrete. The chief argument in support of this 
view seems to be founded on the assertion that the vagina 
possesses no glands. Whether there really are no glands 
in the vagina, or whether, as Von Preuschen and others 
have asserted, there are glands, it must be generally 
admitted that their number is exceedingly limited. The 
presence or absence of glands has, however, but little to 
do with the presence of secretion. 

The primitive secreting medium is a surface, and glands 
in their simplest forms are nothing but involutions, tubular 
or saccular, of this surface. It is true that in some cases 
these involutions undergo a high degree of specialisation, 
and develop powers of secretory activity not possessed 
by the original surface from which they were derived; 
but in their simpler forms the glandular involutions are 
chiefly of service in affording a ready means of increasing 
the superficial area of the secreting surface. 

In. the large intestine, for example, there are a great 
number of simple tubular glands opening on the surface, 
and there seems to be no reason to believe that the cells 
lining these tubules possess any different functions from 
those lining the surface. An increase in the secreting 



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54 YAOINAL B£C&ETIOK. 

surface is obtained in the vagina^ not by a dipping in or 
involution of the lining membrane^ but by the formation 
of ridges or rugsB^ and a similar phenomenon is seen in 
the Fallopian tubes^ where the rugsB thus formed are 
highly complicated. Various types or forms of the 
secretory process are seen in the human body. Secretion 
in its most highly specialised form is seen in the salivary 
glands or pancreas. . Here the gland-cells during a period 
of rest elaborate and manufacture certain specific sub-* 
stances which are stored up in the cells in the form of 
minute granules. During active secretion the substances 
so manufactured are poured out into the lumen of the 
alveolus, and this process is accompanied by an active 
transudation of watery material from the blood, which is 
probably not simply to be regarded as filtration. The 
secretory cells are not broken down or destroyed by this 
process of active secretion, although a certain amount of 
shrinking occurs from the disappearance of the granules 
with which they were previously loaded. A modification 
of this process is seen in mammary secretion. In this 
case there is a manufacture and storage of materials in 
the gland-cells, but the expulsion of these materials into 
the alveolus of the mammary gland is attended with 
partial destruction of the secreting cell itself, the broken- 
down liquefied cell-substance forming one of the constitu- 
ents of the milk. The sebaceous glands illustrate a still 
further modification of the process of secretion. These 
glands are formed as solid diverticula of the Malpighian 
layer of the epidermis. In these glands the cell-substance 
of the central cells — ^that is, those most distant from the 
basement membrane — is constantly undergoing changes 
of a fatty nature. The nuclei of these cells shrink, and 
the cells loaded with fat are thrown ofE and discharged, 
these altered cells themselves forming the secretion. To 
quote a sentence from Poster, ''the secretion of sebum is, 
in fact, a modification of the particular kind of secretion 
taking place all over the skin, and spoken of as shedding 
of the skin.'^ 



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VAGINAL S£CKKTION. 55 

In structure the vagina is very similar to the Malpighian 
layer of the epidermis, and the process of secretion from 
the vagina mainly consists in a desquamation or shedding 
of the superficial layers associated with a certain amount 
of active transudation of albuminous fluid. The type of 
secretion seen in the vagina appears to be closely analo- 
gous to that of the sebaceous glands, and though widely 
different from the process as observed in the parotid or 
submaxillary glands, yet none the less does it deserve the 
name of secretion. In sebaceous secretion the cell-nucleus 
has disappeared, and the cells are found loaded with fat. 
In vaginal secretion the nucleus is still visible. On 
several occasions specimens of vaginal secretion were 
treated with osmic acid, with the object of trying to deter- 
mine whether the epithelial cells present in it showed any 
evidence of fatty degeneration. These epithelial cells, 
untreated by any reagent, present a slightly granular 
appearance. After treatment with osmic acid minute 
black dots are seen studding many of the cells. Whether 
this appearance depends upon the presence in them of 
molecular fat it is not possible absolutely to assert. 

The secretion obtained from the surface of the vagina 
in the above-mentioned cases, where the uterus had pre- 
viously been extirpated, was opaque and whitish in colour, 
very closely resembling in appearance and consistence 
thick starch mucilage. In other cases it was found to 
have a slightly yellowish tinge, so that it bore a close 
resemblance to thick cream. A drop of this fluid examined 
under the microscope showed a large number of flattened 
nucleated cells similar to those covering the surface of the 
vagina. As mentioned above, these cells appear slightly 
granular. The milky appearance which the secretion 
possesses is, no doubt, dependent on the presence of these 
epithelial cells in it. 

Some of the secretion was placed in a test-tube, a small 
quantity of water added, and the mixture then boiled. 
Well marked coagulation resulted. A small quantity of 
the mixture was tested by heating it with nitric acid. A 



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56 TAOINAL 8ECBSTI0N, 

yellow colour was produced, which deepened on the addi- 
tion of ammonia (xanthoproteic reaction). A further 
quantity was tested with copper sulphate solution and 
liquor potassee, and the violet colour showing the presence 
of a proteid substance appeared (biuret reaction). Prom 
these reactions it is clear that vaginal secretion contains a 
proteid material belonging either to the class of native 
albumins or globulins. Mucin also will give the xantho- 
proteic reaction, but not the biuret one, so that though it 
cannot be absolutely affirmed that no mucin is present, yet 
clearly either albumin or globulin is present as well. 

The abundance of the coagulum produced by boiling 
would suggest that mucin, if present, must occur only in 
very small quantities. As no direct evidence of the presence 
of mucin could be obtained, it would seem advisable that 
the use of the expression ''vaginal mucus" should be 
discontinued. It should be added, however, that the 
limited amount of the secretion obtainable for experimental 
purposes might permit of the presence of small quantities 
of mucin being overlooked. 

The reaction of the secretion bathing the vaginal walls 
waa on all occasions found to be acid, and this fact has 
long been known. It has been shown by Doderlein and 
others that bacteria are always present in the vagina. 
The question therefore presents itself, whether the secre- 
tion when poured out from the vaginal surface is acid, or 
whether the acidity is merely the result of decomposition 
due to the action of the bacteria upon it. The following 
experiment was therefore undertaken to determine this 
point. Two plugs of absorbent cotton wool were soaked 
in a strong solution of blue litmus, and then dried. The 
colour of these plugs thus treated was a pinkish violet. 
The vagina of a patient whose uterus had been extirpated 
about six months previously was thoroughly douched and 
swabbed out with a 2'5 per cent, solution of carbolic acid. 
It is proper to state that the reaction of the vaginal 
secretion in this patient had been frequently tested, and 
was always found to be acid. Carbolic acid was used for 



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VAGINAL SECRETION. 57 

the purpose of disinfecting the vagina instead of corrosive 
sublimate lotion^ because the former does not alter or 
destroy the colour of blue litmus^ whereas the latter turns 
blue litmus red, even when no acid is added in the 
preparation of the lotion. The vagina having been 
thoroughly cleansed in this way, the plug of prepared 
cotton wool which was first wrung out in the carbolic 
lotion was passed up to the fundus of the vagina, and the 
lower part of the vagina was then plugged with iodoform 
wool. At the end of eighteen hours the plug was removed. 
It was found to be bathed with a sticky secretion, and had 
turned a bright blue colour, showing that it had been in 
contact with a secretion possessing an alkaline reaction. 
As a control experiment the other plug was in like manner 
wrung out in a 2*5 per cent jsolution of carbolic acid, and 
then placed on one side for the purpose of comparison 
with the plug which was introduced into the vagina. 
This was done to eliminate the possibility of the carbolic 
acid having any efEect upon the colour. No change was 
observed in this second plug. 

This experiment points strongly to the conclusion that 
the secretion of the vagina is really alkaline, and that the 
acidity normally found to be present depends on the sub- 
sequent decomposition of the material secreted. This 
experiment would also seem to show that the acid forma- 
tion is the result of the presence and growth of micro- 
organisms, because when these micro-organisms are ex- 
cluded no acidity is developed. Doderlein has shown 
that a bacillus which he calls the bacillus vaginas exists in 
the normal secretion. This bacillus can be cultivated in 
bouillon containing 1 per cent, of sugar, and also in 
agar-agar containing a similar proportion of sugar. It 
seems to grow most readily in fluid media. When the 
nutritive medium contains sugar a free acid is developed. 
This acid he believes to be lactic acid. Working from a 
different standpoint, my own experiments point to the same 
conclusion as those of Doderlein, namely, that the acidity 
of the vaginal secretion is due to micro-organisms. 



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58 VAGINAL SECRETION. 

Doderlein^s experimentSi as far as I have been able to 
follow them^ do not seem to me to prove more than that 
the vagina contains a bacillus ; and that this bacillus^ if 
cultivated in a fluid medium containing sugar^ gives rise 
to free lactic acid. My experiments show that if bacteria 
are excluded from the vagina the secretion poured out is 
alkaline. 

The conclusion that may be drawn from these two sets 
of facts is that the acidity of the vaginal secretion depends 
on the presence of bacteria. The conclusion of Doderlein 
that the acid present in the vaginal secretion is lactic acid 
does not seem to me to be warranted by his experiments. 
All that he really proves is that the bacillus vaginad can 
convert sugar into lactic acid. There is no evidence that 
there is sugar in the vagina. Owing to the difficulty in 
obtaining more than a very small quantity of normal 
vaginal secretion, experimental inquiry into the nature of 
the acid present must necessarily be unsatisfactory. In 
Von Jasch's work on ' Clinical Diagnosis * the following 
method is recommended as a test for small quantities of 
lactic acid. Two drops of Liquor Ferri Perchloridi 
are added to fifty cubic centimetres of water. The 
faint yellow colour of the solution deepens on the addition 
of lactic acid, but not of butyric acid. This test was 
tried in several cases with vaginal secretion, but no 
deepening of the colour could be observed. It may be 
that the quantity added was too small, and that the test 
was not delicate enough to estimate minute amounts of 
lactic acid even if present. By the use of this test, how- 
ever, no direct evidence of the presence of lactic acid could 
be obtained. That the acidity is not due to hydrochloric 
acid can be easily proved. Congo red offers a very deli- 
cate test for this acid, as even when minute traces are 
present the red becomes converted into a dark blue colour. 
Pieces of filter paper were soaked in a solution of Congo 
red and then dried. On moistening strips of this prepared 
paper with the secretion from the vagina no such alteration 
in colour was observed. 



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VAOINAL 8ECSKTI0V. 59 

It is possible that the acidity of vaginal secretion may 
be due to the presence of certain fatty acids^ such as butyric 
acid^ but no direct evidence on this point could be obtained 
because there do not appear to. be any satisfactory tests 
for this substance when present only in minute quantities. 
Butyric acid is found in sebaceous secretion^ and the 
analogy that exists between vaginal secretion and the 
secretion of sebum would suggest that this is the acid 
which is really present. 

Unfortunately I am unable to substantiate this sugges- 
tion by any direct proof, so that the real nature of the 
acid must still remain undecided. 



The Pbesident thanked Dr. Gow for his interesting contri- 
bution to physiological knowledge, and expressed his admiration 
both of the trouble Dr. Gow had taken to get a correct result, 
and of his ingenuity in devisiDg experimental methods of solving 
the problem he had approached. 

Dr. Lbwebs said he had had the opportunity of examining 
scTeral of his cases of vaginal hysterectomy at times subsequent 
to the complete healing of the wound at the top of the vagina, 
and he had not observ^ that the vagina in these cases was less 
moist than normal. 

Dr. HoBBOCKB said he had always believed in a vaginal 
secretion, and he considered Dr. Gow's facts good proof. At 
the same time he thought more facts were required before it 
could be accepted that this vaginal secretion was alkaline at 
first, and that it only became acid subsequently through the 
action of bacteria. He was a little sceptical about the invariable 
presence of bacteria in a healthy woman; and even if they 
were proved to exist, then he should argue that they had a sort 
of right to be there, that they were not noxious but friendly 
bacteria, and that possibly they did good. Secretion from 
virgin vagin» would have to be examined before these points 
could be settled, and of course it would only be on rare 
occasions that such secretion could be obtained. He thought 
the subject of considerable importance, not only physiologically, 
but also pathologically in its bearing upon coagulation, dys- 
menorrhoea, &c. 

Dr. €k>w, in reply, said that there had been many experiments 
made to prove the presence of bacteria in the healthy vagina, 
though there was no suggestion that such bacteria were patho- 
genic. He himself had made no experiments in this direction, 
bat, among other things, he had tried to show that if organisms 



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60 TAGIKAL 8BCBETI0N, 

were excluded from the vi^^ina the secretion was alkaline. It 
would he very difficult to carry out Dr. Horrocks's suggestion 
and make experiments similar to those described in the paper 
in single women. Moreover the presence of cervical secretion 
would invalidate the results. 



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ANNUAL MEETING. 

PEBRUAEY 7th, 1894. 

6. Ernest Hbbmak^ M.B., President, in the Chair. 

Present — 66 Fellows and 4 visitors. 

The President declared the ballot open for one hour, 
and appointed Dr. W. Rivers Pollock and Dr. C. Hubert 
Boberts as Scrutineers. 

Books were presented by Dr. Boxall, Mr. J. Bland 
Sutton, and the American GynaBCological Society. 

Bruce Hamilton, L.R.CP.Lond. ; Arnold W. W. Lea, 
M.D. ; William Sutton Pratt, M.D. ; and Hugh R. Smith 
were adnutted Fellows of the Society. 

John Campbell, M.A., M.D. (Belfast), and Henry L, 
McKisack, M.D. (Belfast), were declared admitted. 

The following gentlemen were proposed for election : — 
Thomas Henry Barnes, M.D.St. And. ; Hedley Coward 
Bartlett, L.R.CP.Lond. (Saffron Walden) ; George Arthur 
Harold Comyns Berkeley, B.A., M.B., B.C.Cantab. ; 
Woodley Daniel Betenson, L.R.CP.Lond. ; Robert Herbert 
William Hughes Brabant, L.R.CP.Lond. ; David Brown, 
M.D.Lond. ; Robert Francis Burt, M.B., CM.Edin. ; John 
Henry Chaldecott, L.R.CP.Lond. ; Lennard Cutler, 
L.R.CP.Lond. ; William Gilbert Dickinson, L.R.CP.Lond.; 
John William Dickson, B.A., M.B., B.C.Cantab. ; Henry 



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62 ABSCESS IN ABDOMINAL WALL. 

WilKam Drew, P.E.C.S. (Croydon); Charles Herbert 
Pazan, L.R.C.P.Lond. (Wadhurst) ; Henry Wilkes Gibson, 
L.R.C.P.Lond. ; David Livingston Hamilton, L.R.C.P.Ed, 
(Great Missenden) ; Bernard Pred. Hartzhome, M.R.C.S. ; 
Ernest H. Helby, L.R.C.P.Lond. ; Edward Home, M.R.C.S. 
(Wallingford) ; Wilfrid E. Hudleston, L.R.C.P.Lond.; 
Herbert James Hott, M.D.Aber. (Bromley, Kent) ; James 
P. James, L.R.C.P.I. ; Evan Jones, L.R.C.P.Lond. ; Sidney 
Herbert Lee, B.A., M.B., B.C.Cantab. ; William Lepping- 
well Livermore, L.R.C.P.Lond. ; William Christophep 
Loos, L.R.C.P.Lond. (Great Missenden) ; Albert Stanley 
McCausland, M.D.Brux. (Swanage) ; John McOscar, 
L.R.C.P.Lond. (Watlington) ; William Henry Mondelet, 
M.D. (Brighton) ; Edgar Nicholson, M.R.C.S. ; Solomon 
Peake, M.R.C.S. ; Clement Pound, L.R.C.P.Lond. (Odi- 
ham) ; Cecil Robertson, M.B., C.M.Aber. ; Horace Savory, 
M.A., M.B., B.C.Cantab. (Haileybury) ; Archdale Lloyd 
Sharpin, L.R.C.P.Lond. (Bedford) ; Thomas George 
Stevens, M.D., B.S.Lond. ; Montague Tench, M.D.Brux. 
(Great Dunmow) ; Frank Alex. WagstafE, L.R.C.P.Lond. 
(Leighton Buzzard) ; Thomas Alfred Walker, L.R.C.P.Ed. ; 
and William Alfred Ward, L.R.C.P.Lond. 



ABSCESS IN ABDOMINAL WALL. 
Shown by R. J. Probyn-Willlucs, M.D. 

Ths p^^tient, aged 40, was adnutted to the General 
Lying-in Hospital for her fourth confinement. Labour 
was well advanced, but the head had not engaged in the 
brim owing to contraction of the pelvis, the true conjugate 
being afterwards found to be three inches. She had beeu 
advised to have labour induced at the seventh month. 
For the last month of the pregnancy she had frequently 
complained of intense pain over the pubes. Forceps were 



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ABSCESS IN ABDOMINAL WALL, 63 

applied without result, and the prolapsed cord being 
pulseless the child was delivered by cephalotripsy, which 
was easily accomplished. The temperature on the follow- 
ing morning was 102°, but fell to normal the same evening, 
and remained so till death on the morning of the fourth 
day. There was blood and pus in the urine on admission. 

After delivery the patient suffered from incontinence, 
so that no urine could be saved for examination till jast 
before death, when about half an ounce of almost pure blood 
was withdrawn by catheter. This incontinence, together 
with pain and tenderness over the pubes, constituted the 
only symptoms she presented, except rapidity of pulse and 
breathing. The lochia were normal, and the bowels 
acted freely on the third day. The patient seemed to be 
going on well till the morning of the fourth day, when 
she suddenly became collapsed and comatose, and in spite 
of all efforts she sank and died in five hours. 

Two years previously she had had severe pain in the 
left loin, which suddenly ceased, and soon afterwards she 
passed a small stone by the urethra. 

On post-mortem examination there was found a diffuse 
abscess burrowing among the layers of muscle and con- 
nective tissue of the anterior abdominal wall. This 
evidently communicated with the bladder, which was 
found contracted and contained pus. 

Some sticky lymph was found connecting the anterior 
surface of the uterus and adjacent coils of small intestine 
to the anterior abdominal wall, but there was no general 
peritonitis. The uterus and vagina were normal and 
uninjured. 

In the lower part of the pelvis of the left kidney a small 
calculus was embedded, similar to the one the patient 
passed two years ago. Apart from this both kidneys and 
all the other organs were normal. 

The course of events in this case wa-s not quite clear, but 
probably the continuous pressure of the large and firmly 
ossified head before delivery assisted in producing this 
abscess as the result of ulceration of the bladder and 



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64 UTERINE FIBROIDS BEMOVED BY ENUCLEATION. 

extravasation of urine into the connective tissue. The 
abscess probably ruptured either during labour or soon 
after, and this allowed of fatal septic absorption. 



UTERINE FIBROIDS REMOVED BY ENUCLEA- 
TION FIFTEEN DAYS AFTER DELIVERY. 

By Robert Boxall, M.D., M.R.C.P. 

Thebe are three fibroids, one as large as an orange and 
two smaller ones not much larger than a walnut, of soft 
consistence, removed by enucleation from the uterus of a 
woman 35 years of age. She had had five children, and 
one miscarriage before the last child. All the labours 
had been difficult and mostly required forceps. The last 
birth took place at term. Owing to difficulty in removing 
the placenta and to the unusual size of the uterus 
Dr. E. J. Nix, who attended the labour, inserted his 
hand and discovered three fibroid masses situated in the 
upper part of the anterior uterine wall. For six days the 
patient went on well, then labour-like pains set in, followed 
by a persistent high temperature varying from 103° to 
104° or 105° F. The pains became so severe that in spite 
of morphine, given both by mouth and subcutaneously, she 
was unable to sleep. A slight sanguineous loss continued. 
The pains increased in duration and severity, and the 
patient became worn out and exhausted as in a prolonged 
labour. The cervix was sufficiently dilated to admit the 
index finger, and high up the mass could just be reached. 
Under the circumstances it was hopeless to expect expul- 
sion of the mass by natural efforts with the aid of ergot. 
The cervix was accordingly stretched by hydrostatic 
dilators under an ansBsthetic. Attached to the large 
mass a small polypus was found, which, when pulled upon, 
broke away from its attachment. The capsule of the 



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▲C£PHALOnS ACARDIAC FOSTUS. 65 

main mass was broken through and enucleation effected 
by the finger^ an ecraseur wire being employed as a snare 
for the purpose of bringing the upper part within reach. 
Another small mass embedded in the wall immediately 
below the main fibroid was enucleated in like manner. 
The patient has since done well. 

Spontaneous expulsion^ or attempt at expulsion of 
uterine fibroids after delivery, is well known. The in- 
terest of this case lies in the severity of the labour-like 
process by which the uterus endeavoured to expel the 
growth, and in the shortness of the interval which had 
elapsed since the birth of the child. 

Dr. Braxton Hicks described a case which occurrdd to an 
old friend of his maDj years ago» where, three or four days after 
delivery, there were severe after-pains with hsBinorrhage. The 
uterus was explored by the hand, and a large polypus attached 
to the fundus was found ; the pedicle was small ; it was fretted 
through with the thumb-nail, and then it came away. The 
specimen was in Guy's Museum. 

Dr. Champkbys said that he bad collected cases of the kind 
and had discussed them in the ' St. Bartholomew's Hospital 
Beports ' some years ago (vol. xiii, 1877, p. 109). The common 
time after labour for their expulsion seemed to be five to six 
weeks (p. 121). This was explained by the fact that a real 
polypus of the body was incompatible with pregnancy, and that 
it usually took a considerable time for the interstitial fibroid to 
work its way into the uterine cavity and be expelled. 



ACEPHALOUS ACAEDIAC FCETUS. 
Shown by Dr. Herman, for A. W. Grooono. 

A CoMMiTTES, consisting of Mr. Bland Sutton, Dr. Giles, 
and Mr. Grogono, was appointed to report on this specimen. 

VOL. XXXVI. 5 



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66 



TUBAL GESTATION OF NINE WEEKS' DUEA- 
TION SUCCESSFULLY REMOVED THREE 
HOURS AFTER RUPTURE. 

By William Dukcan, M.D. 

Dr. William Dukcak showed this specimen, and gave 
the following history of the case : — Mrs. H — , aged 35, 
has had two children (ten and eight and a half years old) . 
No miscarriages. After the last confinement she is said 
to have had an attack of pelvic peritonitis. On January 
19th, 1894, she consulted Mr. Evan Jones, of the Goswell 
Road, saying that she had (a) morning sickness ; (6) 
cessation of the menses for seven weeks; (c) pain after 
food ; (d) loss of appetite ; (e) swelling and tenderness of 
the breasts ; and (/) more or less pain in the lower 
abdomen for the the last four or five weeks. Mr. Jones 
considered her to be pregnant and treated the sickness 
and dyspepsia. On January 24th Mr. Jones was sent for 
and found the patient suffering from pains (like labour 
pains) in the abdomen and back, with a slight discharge 
of blood per vaginam. The os was soft, not dilated, and the 
uterus apparently enlarged. No clots or membrane of any 
kind were passed. She was treated by rest in bed and 
opium, so that five days later all pains had gone, and she 
felt well. On January 30th she went for a walk, and did 
so for the next three days. 

On February 2nd, at 10.30 p.m. (after supper) she went 
upstairs, and almost immediately after her husband heard 
a groan, and on going to her found her on the floor, 
apparently dying. Mr. Jones (who lives close by) saw 
her in a few minutes, and found her perfectly collapsed, 
pulseless, and extremely pale. A small quantity of brandy 
and water was administered, soon after which she was 
sick, and her pulse became perceptible. Mr. Jones 
diagnosed ruptured tubal gestation, and at once sent for 



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TUBAL GESTATION. 67 

me , meanwhile the patient was gently lifted from the floor 
on to the bed, her head being kept low. 

On my arrival at 11.80 p.m., I found her blanched, pulse 
extremely rapid and just perceptible. The abdomen was 
slightly distended, tender to touch, especially on the left 
side, and dull on percussion everywhere. Nothing abnormal 
was made out on vaginal examination. 

I agreed with the diagnosis, and advised speedy abdo- 
minal section. As, however, she had rallied somewhat, it 
seemed to me that the hasmorrhage had probably stopped 
for the time being, so before operation I got the trans- 
fusion apparatus with saline solution ready, also obtained 
a trained nurse, and arranged a table for the operation. 

At 1.30 a.m. (three hours after the seizure) ether was 
administered by Mr. Jones, and with the assistance of Mr. 
S. H. Lee (my obstetric house physician) I performed abdo- 
minal section. On opening the peritoneum a large quantity 
of fluid blood gushed out. I rapidly examined the left uterine 
appendage ; this felt normal, but on passing to the right 
side a tumour was at once felt ; this was easily drawn out, 
and proved to be the Fallopian tube distended ; the broad 
ligament was transfixed in the usual way, and the tube and 
ovary removed. Several very large clots were squeezed 
out, and smaller ones removed by means of sponges held in 
ovum forceps ; some of the clots were found near the liver. 
No flushing of the peritoneal cavity was resorted to. The 
wound was sewn up, dressed with salicylic wool, and the 
patient removed to bed. 

During the administration of the ether the patient's 
pulse distinctly improved, so that I did not think it neces- 
sary to perform transfusion. 

The patient made an excellent and uninterrupted reco- 
very. 

There were three points of interest in the case : 

(a) The positive and accurate diagnosis made by the 
general practitioner. 

(6) The abdomen was not flushed. 

(c) Transfusion was not performed ; had it been done. 



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68 TUBAL GESTATION. 

doubtless the patient's recovery would have been said (by 
some) to be due in great measure to this. 



Description of Specimen, 

The specimen consists of the right ovary and Fallopian 
tube. The ovary appears normal, measures 4^ cm. long by 



Right ovary and tabe, showing irregnlar rnptnre in tnbe. 

2 cm. broad. On section it presents a large corpus luteum 
2 cm. in diameter, but 1^ cm. of this represents a cyst con- 
taining a whitish fluid, which under the microscope shows 
numerous fat granules. The border of the cyst is of a yellow 
colour. The Fallopian tube is distended in its outer two- 
thirds, measuring 8 cm. long, 4 cm. broad, and 4 cm. thick. 
On its posterior and inferior aspect is an irregular aper- 
ture 1 cm. in diameter through which blood-clot is protrud- 
ing. On longitudinal vertical section the interior of the tube 
is occupied by a blood-clot, which is thickest at the outer 
part, where it measures 2 cm. In this clot is situated a 



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68 TUBAL eBaTATK>9. 

doabtlesB the patient^s recovery would hare been said (by 
some) to be dae in great measure to this. 



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TUBAL GESTATION. 69 

cyst 3 cm. in diameter containing clear fluids lined by a 
distinct smooth membrane^ and having a foetus 1 cm. Iong« 
attached by a distinct umbilical cord to the wall opposite 
the thickest portion of the blood-clot. 

The foetus itself shows a distinct cephalic process, which 
is flexed and on the anterior surface of which two depres- 



Tabe laid open, showing amniotic cavity, fostut, and ambilical cord 
•orroanded by blood-olot. 

sions can be made out (eyes) . There are also rudimentary 
limbs. 

Dr. CuLLiNOwoRTH asked Dr. Duncan if any of the effused 
dot had become adherent. 

Dr. BozALL remarked that in some cases advantage might be 
taken of the absorbing power of the peritoneum to restore fluid 
to the bloods In one case where the patient had lost a consider- 
able amount of blood from a ruptured tubal sac he noticed a 
marked improvement in thepulse consequent upon pouring hot 
water into the abdomen. The operation took place in a farm, 
house where the quality of the water was not above suspicion, 
but care was taken to boil it previously. No special apparatus 
was required, the water being poured from a ewer directly into 
the abdomen. 



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70 TUBAL GESTATION, 

Dr. HoBBOCKs hoped that this cajse would not deter anyone 
from using saline injection. He pointed out that it was a case 
\n which not much blood was effused, and the patient's symptoms 
might have been largely due to shock, seeing that the operation 
was performed three hours after rupture, and it was his ezperi* 
ence that the saline intravenous injection was not so useful iu 
cases of shock as in cases of haemorrhage. 

Mr. Albak Dobak asked for Dr. Duncan's opinion on primary 
hsBmatosalpinx — that is to say, hsBmorrhage into the tube not 
caused by the rupture of a foetal cyst. The majority of cases of 
hsematosalpinx were undoubtedly due to tubal gestation. What- 
ever the pathology of a ruptured tube might be, the surgical 
indication was immediate operation. 

Dr. Bbaxtok Hicks said that in estimating the comparative 
value of transfusion in the various cases which came before them 
as obstetricians they must bear in mind the different conditions 
under which blood was lost. In cases of the surgical kind where 
they had the flow under complete control, as in the case narrated, 
it was very different to the floodings of labour, where, although 
they might have restrained it, yet they were not certain that the 
uterus might not relax again. 

Dr. Dakin wished to ask, in reference to the infusion of 
saline fluid contemplated by Drt Duncan, whether he had 
intended to do this before operating or after. If it were done 
before the bleeding vessels in the broad ligament were secured, 
the raised blood-pressure would undoubtedly increase the 
haemorrhage into the abdominal cavity and cause further loss 
of corpuscles. Such an infusion done simultaneously or almost 
simultaneously with treatment of the bleeding vessels, as in one 
or more of the cases recently recorded by Dr. Horrocks, would, 
no doubt, be the most valuable procedure ; or infusion afterwards 
would be useful in preventing the death from " shock " which 
sometimes follows in such cases. No doubt Dr. Duncan would 
have adopted the simultaneous method, but this had not been 
made quite clear in his description, and it was, of course, a 
matter of great importance. 

Dr. William Dukcak said that none of the clots were adhe- 
rent, for they were all freshly formed. He did not flush the 
Seritoneal cavity because he did not think it necessary ever to 
o so when it contained simply recent blood; although, no 
doubt, some of the fluid used in flushing would get absorbed, 
he considered it of more importance to rapidly finish the opera- 
tion. He did not object to transfusion, but he pointed out that 
this case (in which several pints of blood bad been suddenly 
poured out) recovered just as surely and rapidly as if the 
patient had been transfused, whilst she escaped the risks inci- 
dental to this procedure. He thought that transfusion should 
never be done before the abdomen had been opened and the 



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TUBAL GESTATION. 71 

bleeding yessels secured, otherwise the increased blood-pressure 
brought on by the transfusion would ib all probability cause 
fresh bleeding. If, however, plenty of assistance was obtain- 
able, both operations might be done simultaneously^ The 
question as to whether the case was one of merely a hamato- 
salpinx rupturing or one of tubal gestation could only be 
positively decided on opening the specimen (this had not been 
done at the time it was shown), but he did not think a simple 
hematosalpinx if it ruptured would give rise to such a profuse 
loss of blood as had occurred in this case. Although Dr. 
Spencer objected to a diagnosis of ruptured tubal gestation 
having been so positively made before operation, he (Dr. Duncan) 
would like to know what else it was likely to. be ; here was a 
woman who had seen nothing for nine weeks, who complained of 
morning sickness, swelling of the breasts, pain in the lower 
abdomen, and an irregular discharge of blood j^er vaginam, and 
who was suddenly seized with all the signs of profound internal 
hemorrhage. He trusted that in every case with a similar 
history which came under Dr. Spencer's care, if he did not 
diagnose ruptured tubal gestation he would at all events open 
the abdomen to find out the cause of the hsBmorrhage. He 
agreed with Dr. Spencer that it was unnecessary to flush the 
abdomen when blood had been recently effused into it, but he 
was surprised to hear anyone say that flushing should never 
be adopted under any circumstances. Surely in those cases 
where a Fallopian tube full of pus or a suppurating ovarian 
tumour ruptui^ during removal, and the pus escaped all over 
the intestines and into the pelvic cavity, the only chance of 
saving the patient's life was to thoroughly and freely flush out 
the abdominal cavity. In conclusion, he wished to say that all 
the merit in the case related was undoubtedly due to Mr. Evan 
Jones for his accurate diagnosis and the prompt measures he 
took to have the operation performed, thus saving the woman's 
life. 



Annual Mebtjnq. 

Thb adoption of the laws as revised was put from the 
Chair and passed unanimously. 

The audited balance-sheet of the Treasurer (Dr. Potter) 
was read. 

It was moved by Dr. West and seconded by 
Mr. Malcolm^ and carried — " That the audited report of 



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72 



BALANCE-SHEET. 




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SEP0BT8 OF C0MMITTEK8. 73 

the Treasurer just read be received^ adopted, and printed 
in the next volume of the 'Transactions.' '* 

The report of the Honorary Librarian (Dr. Dakin) was 
then read. 

Dr. Champnkts moved, and Dr. Spencer seconded — 
" That the report of the Honorary Librarian be received, 
adopted, and printed in the ' Transactions.' " This was 
carried. 

Report of Honorary Librarian. 

"The Library contains 4667 volumes, of which 203 
have been added during the past year. 

'' 131 of these volumes, including one made up of 15 
tracts, have been presented to the Society, a very large 
proportion, 96, being the gift of Sir William Priestley. 

" The books bought number 13, with 13 tracts 
(1 volume). The most important addition probably is 
Hirst and PiersoFs 'Human Monstrosities,' a well-illus- 
trated and reliable work. 

" The periodicals have been bound into 58 volumes. 

"W. E. Dakin, 

'' Hon. Librarian." 

The Annual Report of the Chairman (Dr. Champneys) 
of the Board for the Examination of Midwives was then 
read. 

Report of the Chairman of the Board for the Examination 
of Midwives. 

" The number of candidates for the Society's certificate 
continues to increase. 

" During 1893, 339 candidates applied, of whom 296 
passed, 40 failed, and 3 were absent from the whole or 
part of the examination. 

"From 1872 to 1892, 1677 candidates applied, of whom 
1376 passed, 288 failed, and 18 were absent. 

^In all 2016 candidates have offered themselves, of 



"1 



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74 REPORTS OP COMMITTEES. 

whom 1672 have passed, 323 have failed^ and 21 were 
absent. 

" One midwife, A. A. Francis, was erased from the 
register by order of the Council on February 1st, 1893, 
having been convicted of manslaughter. 

" The total number of midwives on the register at the 
present time (including those who passed in January, 1894) 
is 1749, 3 in all having been erased for misconduct. 

" It will be seen that the proportion of failures in the 
years previous to 1893 is about 17 per cent.; in 1893 
about 11 per cent. 

" F. H. Champneys." 

It was moved by Dr. Gervis, seconded by Dr. Amand 
RouTH, and carried unanimously — " That the Report of 
the Chairman of the Board for the Examination of Mid- 
wives be received, adopted, and printed in the ^ Transac- 
tions.' " 

The President then delivered the Annual Address. 



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75 



ANNUAL ADDRESS. 

In the annual address of its President the Society has 
been accustomed to. expect a survey of its year's history 
from three points of view : first, its material prosperity ; 
secondly, the work it has done ; thirdly, its losses by death. 

First, as to its material prosperity. I have to con- 
gratulate the Society upon an increase in the number of 
its FellQws. By death, resignation, and erasures we have 
lost 41 during the year; but we have elected 64 new 
Fellows, making a net gain of 23 — a larger addition to 
the Society^s Fellowship than has been the case for 
several years past. We now number 731 Fellows: 715 
ordinary and 16 honorary. 

An increase in the number of Fellows brings with it 
some addition to our income, and therefore improvement 
in our financial position. Our balance-sheet this year is 
better than that of last year : but this improvement is not 
entirely due to a larger subscription list; it has been 
partly brought about by the self-sacrifice of the members 
of the Board for the Examination of Midwives. It is a 
source of legitimate pride to the Society that for many 
years its Fellows conducted examinations for midwives 
without any remuneration other than the satisfaction of 
having acted for the public good. As soon as the 
Council found that it was able to remunerate those who 
worked at its request, this was done. In view of the 
unsatisfactory balance-sheet of last year, the members of 
the Examining Board have, in order to put the Society* s 
finances in a sound condition, relinquished part of their 
honorarium. 

The report of the Chairman of the Midwives Board has 
been read. The steady increase of applicants for the 



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76 ANNUAL ADD&ESS. 

Society's certificate shows that it is valued^ and that the 
Society meets a public want by holding its examinations. 

The report of the Honorary Librarian has informed you 
of the growth of our Library. 

The Council has spent much time during the year in 
revising the laws of the Society. The revised laws have 
been submitted for your adoption this evening. Although 
the alterations are many, they do not make any important 
change in the practice of the Society. Most of them are 
verbal, aiming at greater clearness and conciseness. 
Those which may seem to inaugurate new modes of trans- 
acting the Society's business, in reality only formulate 
that which has already been its unwritten law, sanctioned 
either by resolutions of the Council or by custom. 

The facts in our history that I have just summarised 
represent only the means to the great end for which we, 
as a Society, exist, viz. " the promotion of knowledge in 
all that relates to obstetrics and the diseases of women 
and children." I now come to the most important part 
of the year's record, which is, the work that we have 
done. I take the various subjects we have considered in 
the order usually followed in systematic works. 

First : the physiology and pathology of pregnancy. The 
digestive disturbances of pregnancy stand on the border 
line between physiology and pathology. The morning 
sickness, which is a familiar symptom of pregnancy, is so 
common that it may be considered physiological, and yet 
it is often a cause of impairment of health important 
enough to call for treatment. The different ways in 
which this vomiting has been treated are innumerable, 
and I doubt if a treatment has ever been recommended 
that was not supported by cases of what appeared to be 
success from its use. But before we can draw any sound 
conclusion from what seems to be the effect of treatment 
upon any morbid condition, we need some knowledge as 
to the natural history of that condition ; the causes which 
have set it up, and the course it is likely to run if left 
untreated. 



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ANNUAL ADDRESS. 77 

Common as the sickness of pregnancy is^ we have 
liitherto known next to nothing of the causes on which it 
depends^ although theories^ based either upon a priori 
deduction^ or upon a small number of selected observations^ 
have been plentiful enough. 

At our meeting in July Dr. Giles presented to us a paper 
which adds some new facts to our knowledge. From an 
analysis of three hundred cases he showed that the pro- 
portion of pregnant women who suffer from sickness is 
about two thirds. He showed also that the women who 
suffer most from sickness during pregnancy are those 
who in the non-pregnant condition suffer from menstrual 
pain. Whether this is simply an example of a general 
law, that persons with unduly sensitive nervous systems 
are liable to many kinds of nervous disorders ; that they 
are sensitive not only to pain but also to reflex gastric 
disturbances; or whether there is in these patients a 
peculiarity in the uterus which produces both the menstrual 
pain and the vomiting of pregnancy, we at present cannot 
tell. But our best thanks are due to Dr. Giles for the fact, 
although we have not yet reached its explanation. The 
dependence of the sickness upon general rather than local 
conditions is seen in another broad fact brought out by 
Dr. Giles, which is, that the sickness is least in those 
pregnancies, and at those ages, which according to the 
statistical tables of the late Dr. Matthews Duncan result 
in the largest and strongest children. The distension of 
the uterus by the growing ovum has been by several 
theorists invoked as the explanation of the vomiting of 
pregnancy; and it has been pointed out in opposition 
to this view, that the vomiting as a rule occurs before 
the uterus is distended, and ceases as the uterus gets 
larger. This objection is, I think, unanswerable when 
applied to the theory that the usual vomiting in the early 
months is due to stretching of the uterus. Dr. Giles has, 
however, shown us good reason for thinking that in the 
exceptional cases in which vomiting occurs towards the 
end of pregnancy it is due to distension of the uterus ; for 



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78 ANNUAL ADDRESS. 

he demonstrates that the tendency to vomiting in the later 
months of pregnancy increases with the size of the child. 

Dr. Giles's paper not only contains these additions to 
our knowledge, the fruit of his own research, but an 
epitome (with references to the original publications) of 
the different theories put forth in the past to explain the 
vomiting of pregnancy. The paper is one which, proving 
as it does, by the investigation of cases, facts which were 
not known before, can never lose its importance. 

In another paper, read to ns at our meeting in June, 
Dr. Giles brought a venerable tradition concerning 
healthy pregnancy to the test of numerical record. The 
belief has for ages been current among women, and lin- 
gered long among doctors also, even if it be quite extinct, 
that women during pregnancy had " longings,'* and that 
if these longings were not gratified some harm followed. 
Dr. Giles has investigated this question in three hundred 
cases. He finds that about a third of pregnant women 
have, while in this condition, a craving, unusual at other 
times, for some article of diet, and that this craving is in 
most cases for fruits or vegetables. His figures thus 
show that the popular belief in the existence of 'long- 
ings'' is not without foundation, and the fact that the 
articles of diet which the majority of women longed for 
were essentially the same in nature, I think strongly 
suggests that the craving is nature's indication of a 
physiological need. 

At our meetings in March, April, and June, the impor- 
tant subject of extra-uterine gestation was brought before 
us. In the text-books of twenty years ago, primary and 
secondary abdominal pregnancy were described as gene- 
rally recognised varieties of extra-uterine pregnancy. The 
knowledge of these conditions possessed at that time was 
almost entirely gained from the dissection of dead bodies. 
Since then, operations on the living subject have so added 
to our facts, that views founded largely on the dissection 
of cases in which pregnancy had ended in chronic retro- 
gressive changes have had to be reconsidered. The sur* 



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ANNUAL ADDBESS, 79 

geon who has added most to our knowledge of the subject 
has expressed complete disbelief in the existence of primary- 
abdominal pregnancy^ on the ground that the digestive 
powers of the peritoneum are so extraordinary, that no 
fertilised ovum dropped into it would have a chance of 
surviving. Still, a number of cases have been recorded 
which, in the opinion of those who examined them, were 
instances of primary abdominal pregnancy; and most 
teachers have, I think, hesitated to reject, simply on the 
ground of a prioH improbability, a fact which seemed sup- 
ported by evidence. 

This question was brought under our notice at the June 
meeting. Mr. Doran exhibited a specimen of a foetus in 
the peritoneal cavity. He at the same time put before the 
Society a collection of all the cases he could find recorded in 
which the reporter thought the pregnancy was of the 
primary abdominal variety. Mr. Doran criticised each case,, 
appraised the evidence and indicated the weak points. I 
think we rise from the perusal of this most laborious and 
valuable report able to agree with Mr. Doran in saying that 
the existence of primary abdominal gestation has not 
hitherto been proved ; that in every case that has been 
thought to prove it, the evidence is insufficient to establish 
the fact. Mr. Doran has said the latest word on the 
subject^ and the question will stand as he has left it until 
some new and more convincing evidence is put before the 
profession. 

Ectopic pregnancy occupied us also at the April meet- 
ing ; but the part of the subject then considered was the 
operative treatment of advanced extra^uterine gestation. 
Papers by Dr. CuUingworth, Dr. John Phillips, and Mr. 
Sinclair Stevenson were read. These papers were clinical 
records of cases under the care of their respective authors. 
Dr. CuUingworth successfully removed the foetus and 
placenta four weeks after the death of the foetus at eight 
months' pregnancy ; and Dr. Phillips did the same thing- 
two and a half months after the death of the foetus at six 
months' pregnancy. Mr. Stevenson in one of his cases was. 



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80 ANNUAL ADDRESS. 

aboat to operate a week after the death of the foetus^ but 
the patient died before he could do so. In another case 
albuminuria developed near full term ; Mr. Stevenson 
operated^ and delivered a living child. The operation was 
a remarkable instance of boldness and promptness. The 
gestation was sub-peritoneo-pelvic, the placenta being 
situated in a hernia-like protrusion of the broad ligament. 
In extracting the f cetus the sac was tom^ and the haemor- 
rhage was terrific. Mr. Stevenson pulled the sac up, liga- 
tured it below the placenta with india-rubber tubing, and 
fixed it outside. The patient recovered without a bad sym- 
ptom. The discussion on these papers elicited accounts 
of other cases in the practice of different Fellows, which it 
is to be hoped may one day be more fully put on record. 
It is only by the accumulation of carefully reported cases, 
such as those to which I have referred, that we can learn to 
treat similar cases rightly. 

The later results of extra-uterine pregnancy were illus- 
trated by a specimen shown to us in March by Dr. E. J. 
Maclean. This case ended in death of the foetus at about 
the fifth month of pregnancy, and the subsequent death of 
the mother after two years' continual illness. 

We have been indebted to Dr. Rasch for the opportunity 
of convincing ourselves of the reality of one of the most 
remarkable therapeutic discoveries of modem times, viz. the 
cure of osteo-malacia by the removal of the ovaries. Many 
instances of this inexplicable but unquestionable fact have 
been reported by operators who practise in places where 
this disease is endemic ; but Dr. Rasch's case is, I believe, 
the first in England. Dr. Rasch brought the patient to 
our meeting in December, 1892, and she was subsequently 
examined by a committee appointed by that meeting, who 
reported to us in February, so that there can be no ques- 
tion in this case of the completeness of the cure. 

Four contributions to teratology have been put before us. 
In February we had the report of a committee appointed 
in December to examine a specimen exhibited by Dr. 
Amand Routh. The careful dissection made showed 



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ANNUAL ADDRESS. 81 

ectopia visceram, with retroflexion of the vertebral column, 
and a remarkable deformity of the pelvic viscera, the 
resnlt (1) of non-development of the normal cloacal orifice, 
(2) persistent communication of the bowel with the allantoic 
cavity, and (3) consequent formation of a vesical anus. 

Two specimens of anencephalus have been shown to us, 
one by Dr. Amand Bouth in June, and one by Dr. Stanley 
Ballance in July. Both have been carefully dissected. 
Although there was no defect in the spinal bony canal, the 
canal of the spinal cord in each case was dilated, and in each 
case the supra-renal bodies were very small, a fact the fre- 
quency of which was pointed out in the discussion by Dr. 
Herbert Spencer. It seems to me probable that the co- 
existence of the spinal cord disease and the smallness of 
the adrenals may be more than coincidence, for Charcot 
has pointed out the frequency of haemorrhage into the 
supra-renal bodies in myelitis. In October, Dr. Eden ex» 
hibited to us a fcetus the subject of spina bifida, which he 
had dissected. The case had another point of interest, 
which was that the mother had suffered during pregnancy 
from hydrorrhcea gravidarum. 

It is to be wished that Fellows of the Society generally 
would bear in mind that the best possible use that can be 
made of any kind of monstrous birth is to send it to this 
Society for examination. 

The diseases of pregnancy which lead to abortion have 
been illustrated by a blighted embryo exhibited by 
Dr. Bemfry at our April meeting. In this specimen 
there was reason to think that the chorion had gone on 
developing although the embryo had died. Dr. Griffith 
showed in February a specimen of abortion in which it 
appeared as if the placental site was below the decidual 
cavity, and that, had the pregnancy gone on, the placenta 
would have been previa. The clinical history of placenta 
prsBvia at a later stage was illustrated by specimens 
shown by Dr. Herbert Spencer and Dr. Pollock. These 
two cases were alike in the clinical point that delivery 
was accelerated by tearing through the placenta in order 

VOL. XXXVI. 6 



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82 ANNUAL ADDRESS. 

to extract the foetus. The results were good so far as 
the mothers were concerned, and in Dr. Spencer's case, 
one of triplets, the children were bom living ; thus showing 
that this mode of delivery does not necessarily involve 
foetal death. Dr. Muir exhibited at our October meeting 
a placenta from a case of accidental hsBmorrhage, which 
showed how the placenta had been detached by successive 
haemorrhages at different dates. 

It seems to me that in such cases what we most want 
is information as to the state of the decidua. The old 
theories of the mechanical causation of placenta prsevia 
and accidental haemorrhage seem to me unsatisfactory. 
The production of abnormal situation, and abnormally 
easy detachment, of the placenta by decidual disease is 
quite easy to understand. Disease of the decidua co- 
existing with placenta praevia has been described ; but 
before we can accept as types isolated cases of decidual 
disease along with placental abnormalities we need ex- 
amination of a large number of cases. Repeated abortion 
also appears to me to be more reasonably explained by 
disease of the decidua than by any other local cause. 

We have only had one communication relating to 
practical midwifery, beside the placenta praevia cases to 
which I have referred ; but that one is an important one. 
Dr. Lowers brought before us in October the first patient 
upon whom symphysiotomy has been performed in this 
country ; and the Fellows present had the opportunity of 
satisfying themselves as to the patient's undiminished 
power of locomotion. 

The subject which we discussed in December is one of 
the greatest importance to practitioners in midwifery, 
although its range of utility is so wide that we can hardly 
claim it as belonging to obstetrics. Dr. Horrocks de- 
scribed to us the method of injecting saline fluid into veins, 
and related cases affording convincing evidence of its 
value. By this method we get not only all the good 
effect of transfusion of blood, but a far greater effect, and 
we avoid the chief dangers of the old method. Dr. Spencer 



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ANNUAL ADDRESS. 83 

exhibited his ingenious contrivances for securing the abso- 
lute purity of the fluid injected. The utility and safety 
of this method of rallying patients from collapse after 
severe haemorrhage has now, I think, received sufficient 
testimony from competent persons to take its place as 
a mode of treatment which every one who enters on 
midwifery practice ought to be ready to use. It may be 
useful to remember that Dr. Horrocks was induced, as he 
told us in his paper, to try the effect of the intra- venous 
injection of quantities of saline fluid much larger than 
years ago would have been thought safe, by the late 
Dr. Wooldridge, and that Wooldridge's conclusions on 
the subject were reached by vivisection. It may be said 
that if Wooldridge had not experimented on dogs, the 
benefits of this mode of treatment would in time have 
been gradually found out by experiments on human beings. 
This may be so, but it is by virtue of experiments on 
animals, so unwisely hindered by our legislature, that we 
to-day can use this mode of treatment with confidence. 

Our volume of * Transactions ' for last year contains 
three papers on the puerperal state : one relating to its 
physiology, two to its pathology. The first, a paper by 
Dr. Giles, on the lochia, has supplied a definite want in 
our knowledge of that subject. It is remarkable, con- 
sidering the amount of labour and ability that has been 
given to many small points in the physiology of the puer- 
peral state, that it should have been left for Dr. Giles, in 
1893, to ascertain the average quantity of the lochial 
discharge. The statements on this point in our text-books 
are all based on a paper by Gassner. Now Gassner only 
measured the quantity of the lochia in two patients — a 
small foundation on which to base general statements. 
It now appears that in these two patients the quantity of 
the lochia was much in excess of the average. G-assner's 
estimate was that the average amount of lochial discharge 
is 52 ounces. The quantity lost at an ordinary menstima- 
tion is believed to be from 2 to 6 ounces. According to 
Gkussner, therefore, the quantity of the lochial discharge 



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84 ANNUAL ADDBE66. 

is at least ten times as much as that of ordinary menstrua* 
tion. A monthly nnrse^ if told that the amount lost by a 
lying-in woman was ten times that lost at a monthly 
period^ would^ I think, say that it was a mistake. Giles's 
estimate, 10^ ounces, or between two and three times as 
much as at a menstruation, is consonant with the experi- 
ence of women. His statement is based, not like Gassner's 
upon two cases, but upon sixty-four. One of his cases had 
an amount of discharge a little in excess of Gtiissner's 
estimate, and in this case there was a retained bit of 
placenta. In no other case did the discharge reach half 
the amount observed by Gassner. Giles attributed the 
discrepancy to the use, in his cases, of vaginal douching, 
and so did others in the discussion. Some, indeed, seemed 
to think that the use of douches invalidated Giles's obser- 
vations as representative of natural lying-in. The douches 
may have made some trifling difference, but to my mind 
it is clear that the cause of the discrepancy between the 
conclusion of Gtissner and that of Giles is that Gassner 
measured two exceptional cases, while Giles took a number 
large enough to prevent one exceptional case from greatly 
affecting the result. Giles's results are in harmony with 
the rough impressions of daily experience, while Gassner's 
are not. 

At our October meeting Dr. Boxall submitted to us a 
part of the splendid contribution to the knowledge of 
puerperal diseases which he is putting before the profession 
in instalments ; the slow appearance of which is due to its 
magnitude. A family tree that was begun with the 
founders of the house, and then had the names of 
successive children entered on it as they arrived, carries 
greater conviction of its authenticity with it than one that 
began with the children, and found out their supposed 
pedigree by inquiry into the past. Most theories as to 
the origin of puerperal disease have been constructed 
according to the latter method, beginning with the disease 
and then extending inquiry back for its supposed causes. 
Boxall, on the contrary, begins with the parents, that is^ 



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ANNUAL ADDRESS* 85 

with the conditions supposed to cause disease^ and then 
traces the offsprings that is^ the kind and amount of ilhiess 
produced. In former papers he has shown us^ as I think 
in an incontrovertible manner — (1) The influence of the 
scarlet fever poison on lying-in women, and (2) The 
influence of antiseptics and general hygienic measures. 
In this paper which we heard in October we were 
instructed as to the effect of external meteorological con- 
ditions. Dr. Boxall demonstrated that the death-rate 
from puerperal fever, and also the amount of septic illness 
in childbed, is greater during the winter than during the 
summer months; that although more prevalent, septic 
illness is of less severity in winter than in summer ; that 
febrile illness during the lying-in not due to septic causes 
is more prevalent in summer than in winter, but shows 
no difference in severity according to season. Dr. Boxall 
contented himself with marshalling the evidence in favour 
of these broad facts, and refrained from speculating as to 
their explanation. That evidence consists of statistical 
tables, the compilation of which must have involved the 
examination of enormous masses of detail. These tables 
Dr. Boxall put in the form of diagrammatic charts, 
constructed with great ingenuity, so as to enable the 
reader to take in at a glance the import of the numerical 
tables. 

At our meeting in November we had before us a paper 
by Dr. Braxton Hicks, entitled *' A Further Contribution 
to our Knowledge of Puerperal Diseases.'' This was a 
clinical record of cases, not written to support any theory, 
but rather because, as every theory must stand or fall by 
its relation to clinical facts, the accumulation of facts must 
precede final conclusions. Dr. Hicks related cases illus- 
trating modes of production and propagation of puerperal 
fever. This paper, and the discussion which followed it^ 
will, it is to be hoped, help to impress upon those engaged 
in nudwifery practice the safety conferred by antiseptics, 
and the danger of omitting their use. 

The diseases of women apart from pregnancy have come 



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86 .^NNUAL ADDBE88. 

before us during the year^ chiefly by way of the exhibition 
of specimens and the relation of the cases furnishing the 
specimens. We have only had two papers of larger scope 
than this^ and for both of these we have had to thank the 
industry of Mr. Doran. At our meeting in April he put 
Ibefore us an exhaustive examination of a practical matter* 
Of all the details upon which the success of ovariotomy 
depends, there is nothing more important than the 
securing of the pedicle ; and by common consent the liga- 
ture is the most trustworthy way of securing it. This 
granted, the choice of the best material for ligature, and 
of the best knot ; and the various accidents that may 
possibly happen when a ligature is used, become matters of 
high importance. These points were discussed by Mr. Doran 
in his paper, in the light both of large personal experience 
and of laborious examination of the experience of others. 
I need not attempt to epitomise the information it gives ; 
it is enough to say that it is a paper which no one can 
read without being instructed. 

Two interesting specimens of ovarian disease have been 
exhibited to us. One was shown in February by Mr. 
Malcolm. It was a case of non-malignant papilloma 
springing from a small piece of an ovary left behind eleven 
years before at an operation at the time supposed to have 
been a complete double ovariotomy. This case presented 
an additional feature of interest. It afforded another 
demonstration of a fact to which years ago the late Dr. 
Matthews Duncan drew attention, viz. that peritoneal 
adhesions sometimes completely disappear. In this case, 
after the first operation drainage was used, the discharge 
was offensive, and the wound did not heal till the escape 
of some ligatures several weeks afterwards. Nevertheless 
at the second operation, eleven years afterwards, not a 
sign of an adhesion anywhere was present. Another 
specimen was shown at the November meeting by Dr. 
Eden, which exemplified a rare transition form between 
malignant and non-malignant ovarian tumours. It was 
an ordinary ovariau cyst with a small nodule of sarco- 



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ANNUAL ADDRESS. 87 

matons growth in its wall ; as Dr. Eden put it^ ^' a tumour 
just overstepping the borders of malignancy/' 

At our meeting in June we had again to thank Mr. 
Doran for a paper of the highest scientific value. He 
brought before us the question of the spontaneous cure of 
uterine fibroids by absorption. He related a case which 
he had watched^ and in which he was sure that a fibroid 
had been present and had been absorbed. He collected 
in this paper a number of published cases in which a 
similar event had been fully reported by other observers. 
He classified these cases according to the different cir- 
camstances in which the absorption had taken place. Any 
subsequent worker who wishes to judge for himself of the 
strength of the evidence that, fibroids are sometimes spon- 
taneously removed by absorption, will find in Mr. Doran's 
paper that evidence in a compendious form, together with 
the opinion of an acute critic and experienced observer as 
to the value of each piece of evidence quoted* The 
question is not one of merely pathological importance ; for 
during the last few years we have heard much of the 
power of electricity in making these tumours disappear. 
Mr. Doran's paper teaches us that if this happens, it does 
not follow that it is due to the electricity. 

Specimens have been exhibited illustrating other points 
in the natural history of uterine fibroids. Dr. CuUingworth 
showed at our February meeting a large rapidly-growing 
cedematous fibroid of the uterus; Dr. Hayes, in May, a 
similar specimen ; Dr. Boxall, in November, a soft rapidly- 
growing fibro-myoma of the broad ligament. Neither of 
these patients had reached the menopause. Dr. Handfield- 
Jones brought under our notice in June a growth of the 
broad ligament which was described as a *' simple fibro- 
nayoma," and had been growing rapidly during the last 
six months, the menopause having occurred three years 
previously. In view of the statements made by Mr. 
Lawson Tait as to the difEerences between soft fibroids 
and the white nodular variety — that the soft tumours 
grow after the menopause and are not cured by removal 



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88 ANNUAL ADDRESS. 

of the ovaries, while the reverse is true of the hard white 
tumours — ^we want all the information we can get illustrate 
ing the life-history of these growths. Dr. Griffith, in 
February, showed a large fibroid cured by spontaneous 
extrusion through the vagina. Dr. Routh, in November, 
showed a fibroid spontaneously enucleated, which was 
referred to a committee, the report of which will appear 
in the volume for 1894. Dr. Lediard, in July, exhibited 
a sessile fibro-myoma from the supra-vaginal portion of 
the cervix which he had removed by abdominal section, 
simply enucleating the tumour from its bed and tying the 
vessels. 

Two communications illustrating diseases of the Fallopian 
tube have been made to us. A paper was read at our 
meeting in May in which Dr. Lawford Knaggs related a 
case of hsdmatosalpinx. The fact that this condition was 
present was placed beyond doubt by opening the abdomen. 
The main peculiarity of the case was that the patient 
before the operation had repeatedly had sudden unexpected 
discharges of a large quantity of decomposing blood. 
Dr. Knaggs thought these discharges were due to the 
distended tube emptying itself into the uterus, and he 
gave in his paper good reasons for this belief. Another 
point of interest in the case was that it seemed to be 
quite independent of pregnancy. The rarity of such 
cases and the closeness with which this one was observed 
make it one of great interest. The other contribution to 
our knowledge of tubal disease was a specimen of hydro- 
salpinx shown at our meeting in November by Dr. Hayes, 
with a brief clinical history, which it is to be hoped 
Dr. Hayes will at a future time make complete. 

To complete the tale of our work during the year, I 
have only to mention two cases of vesical calculus, one 
brought before us in May by Dr. Hayes, and the other in 
June by Dr. Amand Routh. One was formed round a 
hairpin, the other round a bodkin. In one case ulcera- 
tion of the bladder opening into the vagina had been 
produced. Both cases were easily cured. 



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AKNUAL ADDRESS. 89 

Looking back over the year, I think the Society is to 
be congratulated upon the amount and the quality of the 
work that has been put before it. I doubt if in any year 
of the Society's existence it has produced a volume of 
'Transactions' richer in contributions of the character 
which will stand the test of time. 

I come now to that part of the President's duty which 
consists in acknowledging the debt which we cannot pay, 
our debt to the dead. Shakespeare's words — 

" The evil that men do lives after them. 
The good is oft interred with their bones *' — 

seem to me, as applied to scientific matters, to be the 
reverse of the truth. For all good scientific work lives 
and bears fruit long after he who did it has passed away, 
while all else is quickly forgotten. 

We have lost by death ten Fellows during the year 
1893, and some of them had done work which powerfully 
influenced the practice of their day. I take them in the 
chronological order of their deaths. 

Dr. Peatherstone Phibbs, of Elgin Avenue, died on 
January 15th, 1893, aged forty-four. He was educated 
at King's College Hospital, and became a Member of the 
Boyal College of Surgeons in 1875, and a Licentiate of 
the Boyal College of Physicians of Edinburgh, and Licen- 
tiate in Midwifery, in the same year. In 1879 he became 
a Member of the latter body. In the same year he 
became a Fellow of this Society. He afterwards was 
appointed Physician to the Infirmary for Consumption in 
Margaret Street. He published a report of a case in 
which a patient lived for two months without any suste- 
nance but alcohol ; a case which in his opinion proved the 
value of alcohol as a food. 

Mr. Robert James Hutton, of Stroud Green, was 
educated at St. Bartholomew's Hospital. He became a 
Member of the Boyal College of Surgeons in 1869, and a 
Licentiate of the Boyal College of Physicians pf Edin- 
burgh, and Licentiate in Midwifery, in the same year. 



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90 ANNUAL ADDRBS8. 

He became a Fellow of this Society in 1882. He seems 
to have taken some interest in anthropology^ for he 
was a Member of the Anthropological Institute. He was 
at one time a Member of the Honorary StafiE of the 
HoUoway and North Islington Dispensary. He died on 
February 12th, 1893. 

Dr. Henry Candlish, of Ayr, was educated at the Uni- 
versity of Glasgow. He took prizes as a student, and 
graduated M.D. in 1858 "with commendation." In the 
same year he was admitted a Licentiate of the Faculty 
of Physicians and Surgeons of Glasgow. In 1860 he went 
to Alnwick as House Surgeon to the Alnwick Infirmary, 
which post he held for three years and a half. On retiring 
from it he received a written expression of the high esteem 
in which he was held by the governing body. He then 
commenced practice in Alnwick. He was admitted a 
Fellow of this Society in 1861. He was for twelve years 
Medical Officer to the Workhouse, District Medical Officer 
and Public Vaccinator, and for several years Medical 
Officer of Health. He sent occasional contributions to the 
medical journals. He died on March 18th, 1893. 

Dr. William Hope, of Curzon Street, Mayfair, died on 
March 27th, 1893. He received his professional education 
at St. George's Hospital, becoming qualified to practice in 
1861. He was appointed Assistant House Surgeon and 
then House Surgeon to his hospital, and afterwards studied 
in Paris. He travelled for some time in charge of a 
patient entrusted to his care by Dr. Brodie. He then 
graduated at the University of Aberdeen, taking his M.B. 
degree in 1868, and M.D. in 1870. In 1869 he became a 
Member of the Royal College of Physicians. In 1872 he 
was admitted a Fellow of this Society. 

For some time he was Senior Obstetric Assistant at St« 
Bartholomew's Hospital, taking charge of the out-patient 
and maternity departments under the supervision of the 
late Dr. Greenhalgh. He was also for a time Physician- 
Accoucheur to the St. George's, Hanover Square, Dis- 
pensary. He served for some years on the active staff of 



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ANNUAL ADDRESS. 91 

the Belgrave Hospital for Children, and at the time of his 
death was Consulting Physician to that institution. He 
was for many years on the Staff of Queen Charlotte's Hos- 
pital, first in charge of out-patients, then of in-patients. 
He took a warm interest in the training of nurses and 
midwives, and gave much labour to this end at Queen 
Charlotte's Hospital. 

Dr. Hope was a man of modest and retiring disposition,'; 
he might even have been called diffident. Probably from 
this cause he wrote little, his published works consisting 
only of a few reports of cases. His chief interest was in 
theology rather than in medicine. He was a man of cul- 
ture and refinement, and was much beloved by those who 
had the privilege of his friendship. 

Mr. Key Hardey, of Wardrobe Place, Doctors' Commons, 
E.C., died on May 18th, 1893, aged seventy-eight. He 
came of an old Cheshire family, and was born at Todding- 
ton, in Bedfordshire. He was apprenticed according to 
the old-fashioned plan, and then studied his profession at 
St. Bartholomew's Hospital. He became a Member of the 
Boyal College of Surgeons in 1851, and was then for a 
time Assistant Medical Officer to the Junior School of 
Christ's Hospital. He settled in the Castle Baynard 
Ward of the City of London forty years ago, and prac- 
tised there for the remainder of his life. He became a 
Fellow of this Society in 1860. He was Medical Officer 
to the Provident Association of Warehousemen, Travellers, 
and Clerks. He was also Surgeon to the West City Dis- 
pensary. His energy in the discharge of social duties is 
evidenced by the fact that he was an active Freemason, 
and was for twenty-four years a churchwarden. He is 
described as having been a man of powerful physique and 
strong will, of genial and kindly disposition, hospitable 
and generous. 

Dr. Dennis Sidney Downes, of Moreton Villa, Kentish 
Town, died on August 2nd, 1893, aged fifty. He was 
born at Limerick, and was a nephew of the Very Reverend 
Dr. Downes, Vicar-General of the Diocese. He was edu- 



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d2 AKVUAL ADDRESS. 

cated at the Catholic University, Dublin, and became a 
Licentiate of the Royal College of Surgeons in Ireland in 
1862, and of the Royal College of Physicians of Ireland, and 
Licentiate in Midwifery, in 1863. He came to London when 
a young man. He was admitted a Fellow of this Society 
in 1880. He was Surgeon to the Camden Town Dispensary, 
Honorary Surgeon to the Governesses' Asylum, and Divi- 
sional Surgeon to the Police, the band of which accompanied 
his funeral procession, at which an unusual concourse of 
mourners testified to the esteem in which he was held. 

Dr. William Morse Graily Hewitt was bom at Badbury, 
Wilts, in 1828. His preliminary education was at the 
College School of Gloucester. At the age of seventeen 
he became the pupil of Mr. H. Burford Norman. In 
1846 he matriculated at the University of London, taking 
honours in chemistry, and in October of that year he 
entered as a medical student at University College. His 
career as a student was a most brilliant one ; he won 
many academical distinctions, both at his hospital and at 
the University of London. He became qualified to 
practice in 1850. In this year he went to Paris, and 
attended the clinique of Trousseau. A commission in the 
army was about this time offered him, and he passed an 
examination for it, but went no further. In 1852 he 
commenced practice at Radnor Place, Gloucester Square, 
and in 1853 he married. In 1855 he took his M.D. 
degree, and in 1856 became a Member of the Royal 
College of Physicians. After commencing practice he 
still continued to study pathology and clinical medicine at 
University College Hospital, St. Mary's Hospital, and the 
Marylebone Infirmary. In 1855 he was appointed Sur- 
gical Registrar to St. Mary's Hospital, and while holding 
this oflBce he published reports of cases of fractured spine 
('Lancet,* 1855, vol. i), of perforation of the small 
intestine, and of calculi removed by lithotrity. He soon 
turned from surgery; first to diseases of children, and 
then to that which was to be the main work of his life. 
During 1854 and 1855 he closely watched an epidemic of 



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ANNUAL ADDBE88, 93 

hooping-cough at the St. Marylebone Infirmary, and in 
1855 read a paper upon it before the Harveian Society, 
which was afterwards published as a small volume of 
thirty*nine pages. At this time he seems to have given 
great attention to the diseases of children, for the 
' Lancet ' about this time contains some papers from his 
pen which display the characteristic excellencies of his 
mode of work. He wrote "On Infantile Jaundice'' 
(' Lancet/ 1856, vol. ii, p. 8) ; " On a case of Bronchial 
Phthisis in a Child, with Remarks on the Diagnosis and 
Prognosis of that Affection '' (ibid., p. 484) ; " On the 
Lungs of Children dying from Hooping Cough '' (ibid., 
p. 200, and in the ' Transactions of the Pathological 
Society ') ; "On Acute Tubercular Peritonitis '' (' Lancet,' 
1857, vol. i, p. 29) ; " On Bronchitis and Apneumatosis " 
(ibid., p. 625) ; and others on similar subjects. These papers 
are each based either on one case or on a small number 
of cases, investigated most thoroughly and systematically, 
and fully and exactly reported. Hewitt pondered over 
his cases, sought out and studied all the literature relating 
to them which was accessible to him, and produced a 
logical, complete, and coherent explanation of those striking 
or unusual features of the disease which he thought de« 
manded attention, in language always accurate and care* 
fully weighed. 

In 1856 Dr. Hewitt obtained the Lectureship on 
Comparative Anatomy at St. Mary's Hospital. In 1858 
he was appointed Physician to the Samaritan Hospital, 
and in 1859 to the British Lying-in Hospital. In 1860 
he undertook the duties of Joint Lecturer on Midwifery 
at St. Mary's Hospital Medical School along with the late 
Dr. Tyler Smith; and in 1864 he became Assistant 
Physician-Accoucheur to the Hospital. In 1861 he 
purchased the lease of Dr. Bigby's house at 86, Berkeley 
Square, and removed thence from Radnor Place, and in 
this house he practised throughout the rest of his profes* 
sional career. 

In 1858 Dr. Hewitt was associated with Dr. Tyler Smith 



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94 ANNUAL ADDRESS. 

in the foundation of this Society. He was its first 
Secretary ; and its successful start was due very largely to 
his energy^ courtesy^ and prudence. I have no doubt 
whatever that he himself regarded this as one of the 
greatest and best things that he had done; and it is 
without doubt the most permanent^ for his writings^ like 
all those that belong to a stage in a progressive science^ 
must in time be superseded by others embodying new 
knowledge. But the life of the Society that Hewitt 
helped to found outlasts that of the individuals who com- 
pose it; its corporate life and its corporate usefulness 
will continue and grow, fulfilling in larger and larger 
measure the wish of its founders, long after they and 
their writings have ceased to interest any but the 
medical historian. Dr. Hewitt was Secretary from 1859 
to 1864 ; Treasurer in 1865 and 1866 ; Vice-President in 
1867 and 1868, and President in 1869 and 1870. He 
contributed twenty-one papers to our ' Transactions,' 
beside many reports on specimens. 

Hewitt's high motives in helping to found this Society 
will be appreciated if I recall his own views as to the 
functions and utility of such a Society. There were four 
things he thought this Society should do — ^teaching, 
recording, discussing, and uniting. 

1. On its teaching function he laid especial stress. He 
said, ''As a school of obstetric medicine it has exercised, 
and will continue to exercise, a powerful influence. The 
teaching of the Society I cannot but regard as one of its 
most important functions.'^* 

Referring again to this subject he said : '' This Society 
exists, not simply for the purpose of discovering new facts 
and new principles ; it has another function, and one not 
likely soon to cease, viz., the dissemination of these 
principles; in other words, the education of the rising 
generation of practitioners. This Society is eminently a 
teaching Society, offering opportunities for that correction 
and verification of experience which is so invaluable to 
* Inaugural Address, ' Trantaotlons,' vol. zi. 



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ANNUAL Ai>DR£BS. 05 

those whose experience is limited; upholding also what is 
rights and exercising a wholesome influence on the entire 
body of obstetric practitioners/'* 

2. As to recording Dr. Hewitt wrote: '' We have become, 
as the ' Transactions ' will testify, the depository of the 
carefully obtained experience of eminent observers in, it 
may truly be said, all parts of the world/' f 

3. On discussion he said : '^ The discussions which have 
taken place at our meetings have contributed, we cannot 
say how much, to the mutual improvement of those who 
have taken part in them, to the dissipation of prejudice 
and the discovery of truth/'f 

4. As to union Dr. Hewitt's words upon the Society 
were : " It has formed a centre and bond of union for 
obstetric practitioners throughout the country."* 

I think that in these sentences Dr. Hewitt well de- 
scribed what should be the objects of our Society. We 
want them all, discussion as well as publication, and for 
publication not scientific novelties only, but anything 
likely to help Fellows of the Society in their daily work. 
I cannot pass the last-quoted sentence without re- 
marking that at the time Dr. Hewitt wrote it, the 
Society was eleven years old, and numbered about 600 
Fellows. It is now thirty-four years old, and we have only 
731 Fellows. It is as yet " a centre and bond of union '' 
only for a small number of obstetric practitioners through- 
out the country ; and the continued activity of Fellows of 
the Society in inducing others to unite with us is much 
needed. 

Dr. Hewitt's first paper in the department of medical 
science which he made his own was "On the Coagula formed 
in the Veins during the Puerperal State." This was pub- 
lished in the * Lancet ' of 1858. It is not a report of cases, 
but a careful digest and clear presentation of the work of 
Virchow and others upon the subject. The first paper he 
read before this Society was upon the vesicular mole. In 

* Annual Address, ' Transactions,' vol. xii. 
t Inang^oral Address, * Transactions,' vol. xi. 



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96 AimUAL ABDBE8S. 

it he questioned tlie opinion of Virchow that in this con* 
dition the disease of the chorion caused the death of the 
foetus^ and he urged that the chorionic degeneration was 
subsequent to festal death. 

Dr. Hewitt's well-known work on the pathology, dia- 
gnosis, and treatment of the diseases of women appeared in 
1863. The first edition he described as mainly a summary 
and criticism of the then existing knowledge ; it was chiefly 
remarkable for its novel arrangement, the book being 
divided into two parts, the first treating of diagnosis, the 
second of treatment. Pathology was not discussed. Dr. 
Hewitt was appointed Professor of Midwifery in University 
College, London, and Obstetric Physician to University 
College Hospital, in succession to the late Dr. Murphy, in 
1865. In 1866 he was elected a Fellow of the Royal 
College of Physicians. The second edition of his book 
appeared in 1868 ; its arrangement was modified, pathology 
was introduced, and it was illustrated. In 1872 appeared 
the third edition, in which he fully enunciated the views 
npon uterine pathology with which his name was associated. 
In 1878 he delivered the Harveian Lectures, in which he 
more fully expounded those views under the title of " The 
Mechanical System of Uterine Pathology .'' The fourth 
edition of his book was published in 1882, and differed 
from its predecessors mainly in containing Hewitt's views 
as to mal-nutrition as a cause of uterine disease. 

Dr. Hewitt resigned his appointments as Professor of 
Midwifery at University College and Obstetric Physician 
to the Hospital in 1886, and was then made Emeritua 
Professor. His last important conununication to medicine 
was in 1892, when he wrote a paper on sea-sickness, 
detailing experiments which showed that sickness might 
be produced by disturbed visual sensations. 

I have enumerated only a small part of the work that 
he did. Although his theories upon uterine displacements 
were the most novel and the most distinctive of the work 
that he did, yet he was far from confining his attention to 
this subject. It is only necessary to turn over the leaves 



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ANNUAL ADDBBSS. 97 

of our 'Transactions' to find out that there were few 
subjects embraced under the head of obstetrics and 
gynaecology, in discussion upon which Dr. Hewitt had not 
something worth hearing to say. 

Dr. Hewitt was known all over the world as the 
originator and upholder of certain views as to the patho-p 
logical importance of alterations in the shape and position 
of the uterus, which he regarded as morbid, and which he 
believed to be, directly or indirectly, the great cause of 
most of the minor derangements of health peculiar to 
women. These views were much criticised. They cannot 
be said to be universally accepted. They are fully ac- 
cepted by few, if by any; and by some they are not 
accepted at all. This is not the occasion for discussing 
their pathological correctness. But I shall occasion no 
controversy if I say this, that Dr. Hewitt's writings 
caused a great deal more attention to be given to uterine 
displacements by gynaecologists all over the civilised 
world than had been the case before. He urged his 
views with an ability that impressed the reader, and a 
temperateness of statement that gave weight to his judg- 
ment. Even one who does not accept all his opinions 
may derive instruction from his accurate descriptions of 
conditions some of which are admitted to be abnormal^ 
and from his clear and cautious recommendations as to 
treatment. I venture to predict that his later writings, 
in which he drew attention to the dependence of displace- 
ment on conditions of the general health, are destined to 
receive more consideration than they have yet done* 
Not only was his work able and valuable in itself, but his 
theories, by the antagonism they provoked, became the 
parent of other investigations, by which our knowledge of 
the conditions they referred to ha6 been made more 
complete and accurate than it was before. 

His mode of advocating his opiniotis was altogether 
admirably. We, as Englishmen, are proud of the method by 
which justice is done in our law courts. First one advocate 
urges one side of a case, and then another puts forward 

VOL. xzxvi. 7 



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98 AimUAL ADDBB88. 

the opposite. In the conflict of the two error and false- 
hood are exposed and destroyed^ and truth stands out as 
that which alone can survive the double attack. In 
medical science we get at the truth in much the same 
way^ except that the disputants aim higher than at setting 
out only one side. Each tries to state the whole truth. 
But the phenomena of disease and its cure are so com- 
plex, that no one ever attains this. The forensic advo- 
cate deals only with a small body of evidence strictly limited 
by the forms of law. But he who tries to sum up a 
medical question finds that the facts he has to deal with 
are infinite in number — they are continually being added 
to, and things once supposed to be indisputable shown to 
be incorrect. Hence in our science the most scrupulous 
efforts to state the truth become only statements of that 
side of it which the writer perceives. All that a writer 
on clinical subjects can do is to observe as accurately, and 
set forth what he thinks he sees as clearly, as he can ; 
knowing that truth will be served by setting forth one 
side well, even though considerations of a different kind 
should afterwards be shown to be more important. 
Dr. Hewitt did this in a manner which was a model for 
all of us. Even the most strenuous opponent of Hewitt's 
opinions must, I think, admit this ; that in stating them, 
and urging their adoption, Hewitt never went one jot or 
tittle beyond the evidence he had. He never exaggerated, 
never made sweeping general statements in which excep- 
tions to rule were ignored, never concealed the weak 
points in his case or the defects in the evidence. He was 
not only courteous to his opponents, but he was just. He 
never misrepresented them, never answered arguments 
with adjectives, never attributed low motives. No one 
could study his writings or hear him speak without feeling 
certain that Hewitt was himself entirely convinced that 
his theories were right, and that it was from pure love of 
truth that he wished to see them generally accepted. 
From the very beginning of his career his care to be 
strictly accurate in his facts was conspicuous. In his 



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ANNUAL ADDRESS, 99 

private practice, I learn from those who knew him better 
than I did, he was just as careful neither to fall short of 
nor go beyond the truth in his statements to patients. 
How admirable an example he set may be illustrated by a 
small incident, told me by one of his former residents, which 
I mention, not as being wonderful, but as characteristic 
of Dr. Hewitt. He asked his resident to help him to 
remove a polypus from a private patient. When he came 
to examine the patient he found the polypus had vanished. 
Hewitt made no attempt to explain it, but told the patient 
that he had made a mistake, and that he supposed that 
she had had a miscarriage. 

He is described by a biographer who knew him well 
as '^ a true-hearted man, and a loving friend with a noble 
nature.'' He suffered much from ill-health ; from 
hematuria in his early life, from emphysema and bron- 
chitis later on. He died from ursemia, on August 27th, 
1893, aged sixty-five. 

Dr. Frederick Hall, of Leeds, was the third son of 
John Herbert Lewis Hall, a surveyor and a native of the 
Scilly Islands. He was bom at Tynyrhyd in Cardigan- 
shire on April 2nd, 1837. He was educated at the 
Priars' Grrammar School at Bangor, and apprenticed to 
Dr. Bichards of the same place. He then entered the 
Leeds School of Medicine, bringing with him a eulogistic 
letter from the late Dean Cotton, who, being perfectly 
l)lind, wrote that he had had his eye upon Hall for a long 
time. Mr. Hall became M.B.C.S. in 1858 and L.S.A. in 
1860. After qualifying he became Besident at the 
Northern Dispensary, Liverpool, and then was for three 
years Besident at the Leeds Fever Hospital. He com- 
menced general practice in Leeds in 1864, was surgeon to 
3, poor law district and public vaccinator, and also had 
-charge for many years of the Smallpox Hospital. He 
published a report of cases treated in this hospital 
from 1872 to 1878, in which he demonstrated that the 
mortality in smallppx was governed by the number and 
<;haracter of the vaccination cicatrices. His interest in 



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100 ANNUAL ADDB£SS. 

obstetrics^ his professional zeal^ and the confidence placed 
in him by his professional brethren are shown by the fact 
that he was Secretary to the Obstetrical Section of tha 
British Medical Association at its meeting in Leeds^ 
an appointment made chiefly on account of his personal 
characteristics. He is described as having been a capital 
man of business and a delightful companion. He died 
from renal disease on September 27th, 1893. 

Dr. Charles Clay was the second son of Mr. Joseph 
Clay, a miller and com dealer of Stockport, Cheshire, and 
was bom on December 27th, 1801. Owing to the illness, 
of his mother, he was brought up by a paternal aunt until 
the age of twelve. * His absence from home during the 
early years of his life prevented him from feeling the; 
influence of family ties during boyhood so much as might 
otherwise have been the case, and led to habits of inde- 
pendence, boldness, and self-reliance unusual in the early 
years of life. When his school days were over he was 
apprenticed to Mr. Kinder Wood of Manchester. While 
with Mr. Wood he read much, attended more than five 
hundred cases of labour, and assisted his teacher by making 
diagrams and dissections for his midwifery lectures^ 
When his apprenticeship was over, he was sent, by Mr. 
Wood's advice, to the Uuiversity of Edinburgh. He 
became qualified to practise in 1823. In the same year 
he married, and started in general practice in Ashton- 
under-Lyne. He remained there for sixteen years. 
During this period he had three children, all of whom 
died young, and then his wife also died. In his early 
years he was very active as a Badical politician, and 
edited the ' Ashton Reformer ; ' but for the last fifty years 
of his life he described himself as " Tory to the backbone." 

While at Ashton he took a great interest in geology, 
and wrote a book called " Geological Sketches and Obser- 
vations on Fossil Vegetable Bemains, &c., from the South 
Lancashire Coal-fields." 

Dr. Charles Clay's first published paper on a medical 
subject is said to have appeared in 1823, and to have been 



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ANNUAL ADDRESS. 101 

on the use of ergot of rye. In different biographies of 
him, this paper is variously referred to as having been 
published in the ' Edinburgh Medical and Surgical Journal/ 
the ' Medico-Chirurgical Magazine/ and the 'London 
Medical and Physical Journal/ None of these papers con- 
tain anything with Clay's name, or if they do it is not 
indexed. The last mentioned of them contains an anony- 
mous summary of an article on ergot by Dr. Steams of 
New York, and it is possible thai this anonymous abridg- 
ment may have been Clay's maiden effort in literature. 

In 1839 he removed to Manchester, and with his removal 
began that part of his career which is of chief interest to the 
historian of surgery. In 1842 he performed his first ovario- 
tomy. At that time McDowell and his followers had 
performed in America less than a score of these operations. 
About ten successful cases had been published in England 
by different provincial surgeons. Lizars in Edinburgh 
had had so little success that he had not persevered with 
it. No one had successfully performed the operation in 
London. It showed a grasp of surgical principles, and a 
boldness in acting on them, of no common order, for a 
general practitioner who had no hospital, or o£Scial position 
of any kind, to commence the systematic performance of a 
novel operation of great magnitude. When we remember 
also that this operation was at that time discountenanced 
by the leading surgical teachers of the day ; that the only 
experience to which Clay could point in support of his 
hopes of success was that of an operator in a distant 
country, whose reports of his practice were not at that 
time received with unqualified confidence (for the state of 
American journalism was at that time very different from 
what it is at present, and probably on this account the 
credibility of McDowell's statements was at one time 
denied) ; and that, other than McDowell's experience, there 
had only been some isolated cases, so few in number that 
they were looked on by most as happy accidents ; when 
it is added^ further, that Clay modified the operation in a 
way which, in the view of most of his contemporaries. 



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102 AKKCJAL ADDRESS. 

added to its danger^ although we now know that his 
reasons for doing so were in accordance with sound surgical 
principles^ — ^when we remember all this, our admiration for 
his ability and courage is increased. 

Clay claimed the credit of having been the first to 
operate by the long incision. He says (I quote his own 
words, although his English is less admirable than his 
surgery), ''My experience sets a much greater value on 
having a bold and large incision through the integuments, 
at once affording plenty of room for every manipulation, 
aided by the eye, than to require a subsequent enlarge- 
ment, or to drag cysts or solid masses through small 
openings without a knowledge of what attachments may 
possibly exist behind, unseen, unfelt by the finger, and 
the mischief that might arise in consequence of such pro-* 
ceedings " (' Obstet. Trans.,' vol. v, p. 61). We now know 
that a long incision is only needed in exceptional cases, 
and in such cases we make it without hesitation ; but in 
1842 it was the general opinion that a long incision added 
much to the risk, and it needed clear judgment to see, and 
courage to act on that judgment, that there was greater 
danger in manipulating without the aid of sight than in 
extending the incision. 

Dr. Clay went on operating from 1842 onwards. Al- 
though not the first to perform ovariotomy, he was yet the 
first person who operated on a large series of cases, and 
the first to show by a sufficient number of cases that the 
operation could be done with an average mortality quite 
low enough to justify its performance to cure a disease 
which without it was invariably fatal. To him, therefore, 
the epithet of the "Father of Ovariotomy'' in Europe 
rightly belongs. In 1848 he published in his magazine, 
of which I shall speak presently, a series of 40 abdominal 
sections, 38 of them for ovarian tumours. In 1863 he 
read a paper before this Society in which he gave an 
account of 108 cases of ovariotomy, 74 of them successful. 
In the 'Lancet' of 1865 he wrote a paper in which he 
gave the result of 111 cases of ovariotomy, 77 of them 



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ANNUAL ADDRESS. 103 

successful. It is iuteresting to uote^ as exemplifying 
tlie extreme difficulty of correct inference in matters of 
therapeutics^ that Clay regarded three things as essential 
to success : (1) the long incision ; (2) the opening of the 
bowels by ox-gall before and after the operation ; and (3) 
the maintenance of a proper temperature of the room 
during the operation. In the last point he followed Lizars. 

Clay was not only the first great ovariotomist^ but he 
was one of the first to perform hysterectomy^ and the first 
in the British Empire to perform it successfully. He 
might also, I think, have taken credit for being the first 
to use drainage in abdominal surgery. In a case on 
which he operated in 1843 he found on opening the belly 
that the tumour was hydatid. Having emptied the 
abdomen as far as he judged safe. Clay says, '^ Before 
closing the wound I inserted into the abdominal cavity a 
string composed of about a dozen folds of white worsted, 
twelve inches in length, bringiug one end out at the 
lowest part of the external wound.'' The worsted was 
left in for four months. The patient got quite well. In 
the early ovariotomy cases drainage was in effect con- 
stantly practised, for it was the custom to leave the ends 
of the ligatures long, hanging out of the wound ; but this 
was done because it was not known that silk might safely 
be left in the abdomen to be encapsuled and absorbed ; it 
was not done with the object and intention of securing 
drainage. This case of Clay's in 1843, I think, must be 
the first in which a wound communicating with the abdo- 
minal cavity was deliberately kept open in order that 
drainage might take place through it. 

I find no record of Clay's ovariotomy results after 1865. 
In 1880 he wrote that he had done nearly four hundred 
operations ; but he did not say these were ovariotomies, 
nor give any particulars about them. He is quoted in an 
authoritative work**^ as having performed 395 ovariotomies 
with 101 deaths, but the reference is not given. I can 
find no publication of Charles Clay's relating so large a 
• Tait on ' IXseuet of th« Ovsrie*.' 



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104 AISTNUAL ADDBS88. 

number of cases. Dr. John Clay, of Birmingliiain, pub- 
lished, as an appendix to his translation of Kiwisch on 
disease of the ovaries, a table containing exactly the 
same number of cases, 395, collected from different 
authors, and I cannot help thinking it possible that 
there has been some confusion of the writings of the two 
Glays.* 

Clay contributed copiously to the medical journals 
during the early years of his residence in Manchester. 
He wrote on the therapeutic value of inspissated ox-gall. 
He argued that constipation was often due to deficiency 
of bile, and that therefore the most natural cure was to 
supply the place of the missing secretion with a similar 
product from another animal. He was the first in this 
country to cure varicose veins by Laugier's operation 
with Vienna paste. He invented a speculum for the 
better performance of the operation for strabismus. He 
wrote on the treatment of diabetes by mineral acids, on 
the vomiting of pregnancy, and many other subjects. 
His contributions to the medical literature of his time are 
said to number over one hundred. I cannot refer to 
them all, but those I have mentioned show his originality, 
his versatility, and the wide range over which his activity 
extended. His name will live by what he did for ovario- 
tomy, not by these ephemeral productions. 

Clay deserves respectful remembrance, not only as a 
surgeon of rare boldness and originality, but also as 
having been the founder of the earliest obstetrical journal 
published in this country. This was called ' The British 
Becord of Obstetric Medicine and Surgery,' and its first 
number appeared in 1848. Clay was himself the prin- 
cipal contributor, but many writers sent papers to it, most 
but not all of them being gentlemen practising out of 
London. The journal was a most creditable one, and its 
early decease was a misfortune for obstetric science. It 

• In lome of his biographies Charles Clay is said to have won the Jack- 
■onian Prize at the Royal College of Surgeons. It was won by John Clay, 
not by Charles Clay. • 



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ANNUAL ADDBS88. 105 

died because it was before its time, and therefore was not 
a financial success. Not enough medical men were then 
interested in the progress of obstetric medicine and sur- 
gery to support a journal. Its non-success did not arise 
from any failure to keep up to the intentions with which 
it was started. Dr. Clay says, '' It ha& been a pleasure 
to us to know that our list of subscribers has remained 
firm to near the same number from the commencement of 
our labours, and that it includes nearly all the most 
prominent characters in the obstetric department through- 
out Europe and America. Still the number has not been 
sufficient to secure us from loss, or to encourage our pro- 
ceeding further.'' 

This journal contains reports of many of Clay's early 
cases of ovariotomy. Clay also wrote in it an article on 
the spontaneous evolution of Douglas and the spontaneous 
version of Denman, in which he clearly pointed out the 
differences between these two processes. To use his own 
words, he arranged the cases reported in their proper 
places. The one described by Denman, he pointed out, 
never takes place in the pelvic canal, but always in the 
uterine cavity, while in that of Douglas there is no reces- 
sion of any part of the foetus. 

One most creditable feature of Clay's ' British Record ' 
was the publication with it of translations of rare and 
valuable monographs. He thus undertook to do, for a 
small department of medicine, the work that the Syden- 
ham Society was doing for medicine and surgery as a 
whole. The subscribers to the 'British Record' got 
translations of H. F. Naegele on the Mechanism of 
Labour, of Crantz on Rupture of the Uterus, of Harvey 
on Generation, of F. C. Naegele on Contracted Pelves, of 
De Graaf on the Ovaria, of Puzos on Hasmorrhage, and 
other monographs. 

Dr. Clay wrote a small ' Handbook of Obstetric Surgery ' 
which reached its third edition. In it the chief diseases 
of women and obstetric emergencies are arranged alpha- 
betically, and the treatment of each briefly stated. The 



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106 AJfKUAL ADDRESS. 

work is small and its range large, and therefore brevity is 
a leading characteristic of it. 

Clay, as I have said> had no hospital. All his operations 
were done in private. Some were reported fnlly, some 
scantily. At that early stage of ovariotomy it was not 
known what were the really important points, and there- 
fore even the most detailed reports of Clay's cases are 
often wanting in information about matters that we now 
think vital. Clay was never a methodical man. He 
never published any complete serial record of his cases. 
They are scattered, some in one journal, some in another. 
At that time the debaters in our medical societies were 
very outspoken ; it was publicly said with regard ta 
ovariotomy that the successful cases were published as 
soon as the wound had cicatrised, while the unsuccessful 
were never heard of. From these causes, (1) Clay's 
practice not being public, and (2) his not reporting his 
cases in a way which enabled the reader at once to grasp 
the main results, to refer if he pleased to the details, and 
to satisfy himself of the authenticity of the records, it 
resulted that although Clay had a great local reputation^ 
and was known in every part of the world to the men who 
studied ovarian disease, yet he did not influence the 
opinion of the profession at large so much as, from his 
ability, knowledge, and experience, he ought to have done. 
Clay felt to the end of his life that justice had not been 
done him. I think that when we consider how unfavour- 
able the conditions were under which he worked, what 
difficulties he had to face, and yet how much he did, our 
judgment will be that it was a misfortune for surgery that 
Clay was not early placed in a more conspicuous position. 
Had he worked surrounded by students who could have 
watched his practice, reported his cases, stimulated his 
thought, and imitated his excellences, he would have 
powerfully helped on every department of surgery. As it 
is he remains the first great Eifglidh ovariotomist. 

Clay was a man of varied interests. He collected 
upwards of 1000 editions of the Old and New Testament. 



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ANNUAL ADDRESS. 107 

These were sold by auction in 1883. Like another^ 
eminent obstetrician, Wm. Hunter, he gave part of his 
attention to numismatics. He wrote a work on ^ The 
Currency of the Isle of Man, from its Earliest Appearance 
to its Assimilation with the British Coinage/ and fonped 
a collection embracing every known coin in the kingdom 
of Man. This was sold for £100. He also made one of 
the largest collections ever formed of the copper and 
silver coinage of the United States. This was disposed 
of in New York to the American Government for £800. 
Clay was for some time President of the Manchester 
Numismatical Society, and was a member of several 
similar societies. He died on September 19th, 1893, aged 
nmety-one* 

Dr. Edward John Tilt was bom at Brighton in 1815, 
and received his medical education first at St. George's 
Hospital, and then in Paris. He graduated M.D. at the 
University of Paris in 1839, and afterwards travelled 
as private physician to Count Schouvaloff. In 1859 he 
became a Member of the Eoyal College of Physicians. 
He afterwards was appointed Physician- Accoucheur to the 
Farringdon General Dispensary. He was one of the 
orig^inal Fellows of this Society, was a member of the 
Council in 1867-8, Vice-President in 1869-70, IVeasurer 
in 1871-2, and President in 1873-4. 

Dr. Tilt received the impulse which shaped his profes- 
sional career while studying in Paris. He learned from 
Becamier the use of the speculum, and the treatment of 
the morbid conditions the diagnosis of which was made 
possible by that instrument. Seldom has pupil spoken 
of teacher in terms of more ardent admiration than 
did Tilt of Becamier^ in his first published work, the 
one which, in its later editions, took the title of 
' Uterine and Ovarian Inflammation.' Tilt began 
practice armed with this knowledge, which at that 
time was to many people new. He helped Dr. Henry 
Bennet to make known the value of the speculum, and 
• ' DiMNiet of Menstmation/ 1860, p. 27. 



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108 ANKUAL ADDKE88. 

when Dr. Henry Bennet's health failed^ and he became 
unable to carry on his practice throughout our English 
winter. Dr. Tilt lived in his house and took charge of his 
patients. 

He wrote books on ' Elements of Health and Principles 
of Female Hygiene/ on ' Uterine and Ovarian Inflamma- 
tions/ on ' The Change of Life in Health and Disease/ on 
' Uterine Therapeutics/ and on ' Health in India for British 
Women.* Seven of his papers are in our ' Transactions,* 
and he contributed numerous papers to the medical 
journals of thirty or forty years ago ; the substance of 
these latter was afterwards reprinted in his books. Dr. 
Tilt's writings were valued abroad as well as in this 
country ; they were reprinted in America and- translated 
into more than one European language, and their author 
was elected a member of several foreign learned societies. 

Dr. Tilt's writings are as much out of date to-day as 
books on the geography of Africa written before the 
discoveries of Livingstone. But they will always retain a 
certain value by means of the numerous references which 
they contain to the literature of the subject, chiefly the 
French literature. These numerous references attest the 
trouble which Tilt took to make his work as thorough as 
he could. His books were written in a homely and 
colloquial, rather than an exact scientific style, and they 
contain many not unimportant practical hints omitted 
it may be because thought unnecessary, in most works 
on the subject. He went into great detail about the sub- 
jective nervous symptoms of female diseases. The books 
fulfilled a useful function in extending among the profes- 
sion knowledge which at the time was new. 

It is generally the case that the value of a new mode 
of treatment is found out before the cases in which it is 
suitable have been differentiated. Hence in the history 
of almost every new mode of treatment there is an ex- 
perimental stage, in which the remedy is used for many 
cases in which it is not suitable as well as for those in 
which it is. Experience gradually teaches us to distin- 



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AimUAL ADDRESS. 109 

gaish the cases the remedy will cure from those it will 
not^ and the remedy then takes its proper place. If the 
new treatment be one capable of evil as well as good 
effects, cases are sure to arise during the experimental 
stage in which harm has been done, indignation is 
excited, and the innovators are condemned. As in 
the case of most new therapeutic measures, the value 
of the local treatment of inflammation and erosion of 
the cervix was found out before much was known about 
the symptoms and natural history of these conditions. If 
the speculum and caustic were at one time used too often, 
that was not the fault of Tilt. It was inevitable. He 
did but hasten the period of experiment with this mode of 
treatment. That period must have been passed through 
sooner or later. 

Although one of the promulgators of a new mode of 
treatment looked on at first with much suspicion. Tilt was 
not one who grasped at every novelty that held out pro- 
mise of success. He was eminently conservative. His 
books contain much outspoken criticism of the surgical 
procedures invented by Marion Sims ; and when treatment 
by pessaries was passing through its experimental stage. 
Tilt was as severe in condemning what he considered 
nncalled-f or mechanical treatment as he was in denouncing 
the cutting operations of Sims. 

The esteem which his professional brethren felt for Dr. 
Tilt, and the personal popularity which he had won, are 
shown by the fact that he was the only President of this 
Society who had not been on the teaching staff of one of 
the large general hospitals. 

To the end of his life Dr. Tilt took a warm interest in 
our Society. Although advancing years prevented his 
attendance at our meetings, he used to annually visit the 
library, and inquire as to the progress of the Society. 
He sympathised heartily with the Society^s efforts at im- 
proving the education of midwives ; and one of his Presi- 
dential addresses contains a full account of the Society's 
action up to that time. Dr. Tilt died from cerebral 



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110 ANNUAL ADDB£8S. 

Iiaemorrhage on December 17th, 1893, aged seventy- 
eighth 

All that remains for me to say is to express my thanks 
to the Officers and Council of the Society for their kind 
assistance and support during the year that has passed. 

Dr. Platfair said he had the privilege of proposing a 
cordial vote of thanks to the President for his excellent 
address, and to express the hope that he would permit it 
to be published in the ' Transactions ' of the Society. 

Fortunately this question required no advocacy to re- 
commend it to the acceptance of the Society. Every 
Fellow must have been struck with the constant work 
which Dr. Herman had devoted to the service of the 
Society. His elaborate and interesting address was 
specially to be commended. He was struck with the tact 
and good feeling with which the President had described 
the lives of some of their departed Fellows, whose theories 
they were not always able to accept, but for whose cha- 
racters and labours they all had the highest admiration. 

This was seconded by Dr. Black, and carried with great 
applause. 

The Scrutineers having presented their Report, the 
result of the ballot was declared by the President as 
follows : 

Officers and Council. 

President. — G, Ernest Herman, M.B. 

Vice-Presidents. — ^Alban Doran ; Edwin HoUings, 
M.D. ; Peter Horrocks, M.D. ; Harry Speakman Webb 
(Welwyn) . 

Trea4furer. — John Baptiste Potter, M.D. 

Chairman of the Board for the Examination of Mid' 
wives. — Francis Henry Champneys, M.A., M.D. 

Honorary Secretaries. — ^William Duncan, M.D. ; W. 
Badford Dakin, M.D. 

Honorary Librarian. — John Phillips, M.A., M.D. 



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ANNUAL ADDRESS. Ill 

Other Members of Council. — ^Thomajs^Rutherford Adams, 
M.D. (Croydon) ; Fletcher Beach, M.D. (Sidcup) ; 
Robert Boxall, M.D. ; Andrew Brown, M.D. ; Edward 
Clapham, M.D. ; Archibald Donald, M.A., M.D. (Man- 
chester) ; Lovell Drage, M.D. (Hatfield) ; Willoughby 
Fumer (Brighton) ; William John Gow, M.D. ; Walter S. 
A. Griffith, M.D.; Gerald S. Harper, M.B. ; John D. 
Malcolm, M.B., CM. ; Leonard Remfry, M.A., M.D. ; 
John Henry Salter (Kelvedon) ; John Bland Sutton ; 
Edward Sabine Tait, M.D. ; John Sidney Turner ; John 
Williams, M.D. 

It was moved by Dr. Holman, seconded by Dr. Boxall, 
and carried unanimously — '' That the best thanks of the 
Society be given to Dr. Champneys for his work and zeal 
as Editor of the ' Transactions ' for the past six years." 

Dr. Champnbts replied. 

It was moved by Dr. Pottbe, seconded by Dr. Hates, 
and carried — " That the Society desires its most cordial 
thanks to be given to its retiring officers, viz. Dr. Horrocks, 
Honorary Secretary, and to Dr. Dakin, Honorary Librarian, 
for their valuable services to the Society during their 
respective terms of office." 

It was moved by Dr. Routh, seconded by Mr. J. Sidney 
TuBNEB, and carried unanimously — "That this meeting 
also expresses its best thanks to the retiring Vice-Presi- 
dents, Dr. Thomas C. S. Corry, Mr. Meredith, and Mr. J, 
Enowsley Thornton, and to the other retiring members of 
Council, Dr. F. W. Coates, Dr. Cullingworth, Mr. Freeman, 
Dr. H. Roxburgh Fuller, Dr. Gervis, Dr. Lewers, Dr. 
Perigal, Dr. Rutherfoord, and Mr. George H. Wade.*' 



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MAECH 7th, 1894. 

G. Ernsst Hebman, M.B., President, in the Chair. 

Present — 37 Fellows and 2 visitors. 

Books were presented by Mr. Malcolm, the St. Bar- 
tholomew's Hospital Staff, and the New York Academy of 
Medicine. 

Thomas Herbert Morse, F.R.C.S. (Norwich), was 
admitted a Fellow of the Society. 

Alexander W. W. Dowding, M.D.Durh. (New Wan- 
stead) ; and J. Atkinson Hosker, M.B.C.S. (Bonrnemouth), 
were declared admitted. 

The following gentlemen were elected Fellows of the 
Society : — ^Thomas Henry Barnes, M.D. ; Hedley Coward 
Bartlett, L.R.C.P.Lond. (Saffron Walden) ; George A. H. C. 
Berkeley, B.A., M.B., B.C.Cantab.; Woodley Daniel 
Betenson, L.R.C.P.Lond.; Robert H. W. H. Brabant^ 
L.R.C.P.Lond. ; David Brown, M.D. ; Robert Francis 
Bart, M.B., C.M.Edin. ; John Henry Chaldecott, 
L.R.C.P.Lond. ; Lennard Cntler, L.R.CP.Lond, ; 
Wm. Gilbert Dickinson, L.R.C.P.Lond. ; John William 
Dickson, B,A., M.B., B.C.Cantab. ; Henry William Drew, 
F.R.C.S. (Croydon) ; CharlesHerbertFagan,L.R.C.P.Lond. 
(Wadhurst); Henry Wilkes Gibson, L.R.C.P.Lond. j 
David Livingston Hamilton, L.R.C.P.Edin. (Great 
Missenden) ; Bernard Fred. Hartzhome, M.R.C.S. ; Ernest 
H. Helby, L.R.C.P.Lond. ; Edward Home, M.R.C.S. 
(Wallingf ord) ; Wilfrid E. Hudleston, L.R.C.P.Lond.; 

VOL. zxxvi. 8 



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114 FIBBOID P0LTPU8 OF CSBYIX. 

Herbert James Ilott, M.D. (Bromley^ Kent) ; James 
Prytherch James^ L.R.O.PJ.; Evan Jones, L.B.C.P.Lond. ; 
Sidney Herbert lioe, B.A., M.B., B.C.Cantab. ; William 
L. Livermore, L.B.C.P.Lond. ; Wm. Christopher Loos^ 
L.B.C.P.Lond. (Great Missenden) ; Albert Stanley 
McCansland, M.D. (Swanage) ; John McOscar, L.B.C.P. 
Lend. (Watlington) ; William Henry Mondelet, M.D, 
(Brighton) ; Edgar Nicholson, M.R.C.S. ; Solomon Peake, 
M.R.C.S. ; Clement Pound, L.B.C.P.Lond. (Odiham) ; 
Cecil Robertson, M.B., C.M,Aber. ; Horace Savory, M.A., 
M.B., B.C.Cantab. (HaQeybnry College, Hertford); 
Archdale Lloyd Sharpin, L.B.C.P.Lond. (Bedford) ; 
Thomas Oeorge Stevens, M.B., B.S.Lond. ; Montague 
Tench, M.D. (Great Dunmow) ; Frank Alex. Wagstaff, 
L.B.C.P.Lond. (Leighton Buzzard); Thomas Alfred 
Walker, L.B.C.P.Ed. ; and WiUiam Alfred Ward, 
L.B.C.P.Lond. 



BUPTUBED TUBAL GESTATION. 

By William Duncan, M.D. 

The specimen exhibited at the last meeting was now 
shown laid open ; also a coloured drawing of the same. 



FIBBOID POLYPUS OF CEBVIX. 

Shown by William Duncan, M.D. 

Th£ patient from whom the specimen was removed was 
a single woman aged 34, whose periods were regular from 
the age of fourteen until one year ago, when she began to 
suffer from metrorrhagia, and this had become profuse for 
the last three months, with clots and pain in the lower 
abdomen. 



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FIBKOID POLYPUS OF CBEVIX. 115 

On examination the vagina was found to be filled by a 
large tumour with a smooth and yellowish surface ; the 
cervix uteri could not be felt^ but bimanually the uterus 
was found to be in its normal position. The patient was 
anaesthetised^ an ecraseur wire passed over the mass 
as high up as possible^ then the pedicle was slowly cut 
through; there was no haemorrhage. The tumour was 
next seized with a pair of short midwifery forceps, and 
after a good deal of traction was extracted from the 
vagina. It was then found that its attachment had 
been to the posterior lip of the cervix at its lower part. 
Although there was no external rupture of the perineum, 
there was found to be a vertical rent in the middle of 
the posterior vaginal wall to the extent of quite three 
inches ; the edges of this rent were brought together by 
silkworm gut sutures and the vagina washed out with a 
1 in 3000 perchloride solution. The patient made an un- 
interrupted recovery. 

The tumour, which was as large as a good-sized cocoa- 
nut, showed on section the ordinary fibrous structure. 

Dr. Duncan pointed out how the vagina might be torn 
in delivery without any external rupture of the perineum, 
and the necessity for examining the vagina after every 
case of labour. 

Dr. CvLLiKOWOBTH said, in reference to Dr. Duncan's speci* 
men of uterine polypus, he would be glad to know whether the 
ecraseur (an instrument that he, the speaker, had for some 
years abandoned in favour of the scissors in the removal of 
fibroid polypi) was used in this case as a matter of routine or 
on account of some special circumstance. 

The Pbesident said he used the scissors ivhen the polypus 
was so small that the fingers could reach to its neck to guide 
the scissors. With vexy large polypi, such as Dr. Duncan's, the 
fingers could not get past them high enough to guide the scissors ; 
and in such cases the stalk was best cut through with the 
^nraseur. He did not think the delivery with forceps entire of 
a tumour so large as that shown by Dr. Duncan was good 
practice. It was better to cut the tumour up into bits, and thus 
deliver it without injury to the mother. This could easily be 
done with scissors. 

Dr. Fetbb Hobbocks agreed with the President that in 



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116 FCETUS AT SEVEN MONTHS ILLUSTRATING CELOSOMA. 

large polypi it was impossible to get at the pedicle with scissors. 
He believed it was a mucb quicker methoa to cut through the 
pedicle with a wire 6craseur than to cut pieces out of the 
tumour, and so lessen it until the pedicle could be reached ; and 
this plan was sometimes impracticable, as in the case of a large 
intra-uterine poljpus. He related details of such a case in 
which he assisted Dr. Braxton Hicks to operate. The patient 
was over forty years of age, single and nulliparous. Some 
difficulty was experienced in passing the loop of the wire through 
the OS uteri and oyer the tumour, but this was done, and the 
pedicle was cut through. Then came the difficulty of delivery ; 
midwifery forceps and finally the cephalotribe were used, and 
the tumour delivered. During the operation the cervix was 
split, and the hymen was not merely torn, but pieces of it were 
carried away, and the perineum was laceratcKl. Hence this 
lady now presents a scarred perineum, carunculsB myrtiformes, 
and a split cervix ; and inasmuch as the tumour haa distended 
the abdomen so as to produce similar lines to linese gravidarum, 
it would be a very easy mistake to come to the conclusion that 
she had had a child. From a medico-legal point of view one 
could only say that a laige body had passed along the parturient 
passages. There were no linesd, however, on the breasts of the 
lady. In removing these tumours either by scissors or by wire 
^raseur there was, as a rule, but little hsemorrhage, owing to 
the muscular fibres in the pedicle contracting and remaining 
retracted. 

Dr. DiTNCAN said he agreed with the President that in large 
polypi it was far better and easier to cut through the pedicle 
with an ^raseur than with scissors ; he also agreed that after 
division of the pedicle the tumour should be removed piecemeal 
by means of scissors ; indeed (as the specimen showed), be had 
begun to do this, but then used the midwifeir forceps in order 
to preserve the tumour for exhibition at the Society s meeting, 
the result being a rent in the vagina, which fortunately healed 
without any ill result. 



FCETUS AT SEVEN MONTHS ILLUSTRATINa 
CELOSOMA WITH RETROFLEXION, MENIN- 
GOCELE, AND TALIPES VARUS. 

By Leith Nafieb, M.D. 

A CoKMiTTEE, consisting of Drs. Napier, Giles, and Dakin, 
was appointed to report on this specimen. 



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117 



A PLEA FOR THE PRACTICE OF SYMPHTSI- 
OTOMY, BASED UPON ITS RECORD FOR 
THE PAST EIGHT YEARS. 

By RoBBBT p. Harris, A.M., M.D. (of Phaadelphia), 

HOKORASY PELLOW OV THX AHEBICAK eTVJECOLOaiOAL ASSOCIATION. 

(Commanicated by Dr. Lbwbss.) 

Symphysiotomy has an unfortunate early history, and, 
although its record is not nearly so discreditable as has 
been made to appear by early writers, there was enough 
of truth charged against it to make it an unpopular 
scheme of delivery, and to cause it to gradually die out. 
Too many women died, too many that did not die were 
disabled, and far too many children were lost. We are 
better able now than at any former period to make a 
record of the early days of the operation, and we give it 
as follows. 

What has very properly been called " the first histo- 
rical period of the operation " extended from 1777 to 1858 
inclusive, and we have reason to believe that there were 
150 symphysiotomies performed in the eighty-two years. 
Of this number we have the full results in 114, under 
which seventy-four women and forty-one children were 
saved. This gives a mortality of 34} per cent, for the 
women, or a fraction over one-third ; and 63| per cent, 
for the children, or nearly two out of three. It will 
very readily be seen why the operation was for a time 
abandoned. 

After the revival of the operation in Naples under Pro- 
fessor Morisani, and its much better management by him 
and Professor Novi in 1866, the mortality was reduced to 20 
per cent, of the women (ten out of the first fifty) and 18 per 
cent, of the children. Not being satisfied with this per- 



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118 PLEA FOB THE PRACTICE OF SYMPHYSIOTOMY. 

centage of recovery, these two operators in 1886 began a 
new era of success, by a more rigid teclinique and adher- 
ence to the sub-osseous method of section, aided by strict 
antiseptic precautions; and they, with their followers, 
have shown that fifty women could be operated upon so 
as to save forty-eight of them and forty-four children, 
a mortality of 4 per cent, of the women and 12 per cent, 
of the children. Of the six children lost out of the 
fifty, one was premature, and died ; a second died in 
twelve hours ; a third died from prolapsed cord ; a 
fourth was stillborn, after a labour of eighty-four hours ; 
a fifth lived one day; and the sixth was stillborn. 
The two women that died had been very long in labour, 
one of them ninety-six hours. After such a measure 
of success it is folly to decry the operation, or to claim 
any longer that it is not founded upon a rational basis. 
We may not be able to equal it, but the facts stand, 
and we ought to endeavour to save as large a proportion 
of women and children under it as may be possible. 

In view of these facts, it is not to be wondered at that 
the operation is no longer confined to Italy, but that it 
made an exit in February, 1892, and has since that 
time spread over Europe, and been welcomed in North 
and South America. In 1891 there were twelve ope- 
rations, all in Naples, and in 1892, so far as I have ascer- 
jre were eighty-three in Europe and America, 
of which belonged to Italy. The operation 
ider test in twelve countries, and will pro- 
performed as many as 200 times during the 
)ar, to judge from its great increase up to July 
will no doubt require a probation of several 
)re we can form a fair estimate of the real 
f the operation and its proper measure of 
With many trying it for the first time who had 
essed its performance, we should be encouraged 
;t that but nine cases proved fatal out of the 
ee operated upon in 1892. The possibility of 
best shown by the facts that Prof. Adolphe 



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PLEA FOB THE PBACTICE OF STMPHT8I0T0MT. 119 

Finard of Paris did not meet with a death until it followed 
as a result of his twentieth operation^ and that in the 
United States there has been but one woman lost out of 
the last fifteen up to November 20th, 1893, although 
delivered under twelve operators, ten of whom operated 
for the first time. 

Much better progress has been made, out of Italy, in 
saving the lives of the women than of the children ; and 
it is in the latter respect that time, experience, and know- 
ledge will eventually demonstrate their value. Two lives 
are at stake in the delivery, and if both are not saved 
there should be good and valid reasons for the failure. 
Italy has reduced her fcetal mortality to 12 per cent., and 
this measure should be aimed at in other countries. Of 
the eighty-three children delivered in 1892, ten were 
stiUbom, two were destroyed by cranioclasm, and ten 
died within three days after deUvery, leaving sixty-one 
recorded as saved, or 73} per cent. To save the fostus 
the woman should be operated upon early; the size 
of her pelvis should be accurately ascertained. The 
true conjugate should not measure less than 2} inches ; 
the child should be very carefully, and not hurriedly, deli- 
vered by the forceps applied to the sides of its head, 
and if asphyxiated it should be carefully treated for its 
restoration. 

Very few as yet know, for the details of the case are 
only now in press, that the first symphysiotomy of the 
United States was the third operation of its class which 
was performed after the method ceased to be confined to 
Italy, Prof. Pinard of Paris having had the first and 
second. The operator. Dr. Wm. Thomas Coggin, now 
of Athens, Georgia, was in Heidelberg in 1890, and 
there learned all about the symphysiotomies of Naples 
from an Italian medical student. He lived at that time 
in North-Eastem Alabama, and there, in Wills' Valley, 
he performed his operation, on March 12th, 1892, upon 
the wife of a miner, a primipara of twenty-three, 5 feet 
7 inches high, having a contracted pelvis and a very 



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120 FLEA FOB THE PBACTICE OF BYMPHTBIOTOMT. 

large foetus. After a labour of four lioursj and two 
failures to deliver with forceps of different forms. Dr. 
Coggin, then a ten years' graduate, opened the symphysis 
and delivered under the forceps a male foetus weighing 
11 1 lbs., and having a very large head* The pubic bones 
separated 2} inches ; the sacro-iliac synchondroses were 
uninjured, and the soft parts likewise. The woman made 
an excellent recovery, and she and her boy are now alive 
and well, the latter being a strong baby of twenty-one 
months old. 

This was the first of thirty-one operations in the 
United States, and the foetus was the heaviest of the thirty- 
one, the nearest weighing 10 lbs. Of these children twenty- 
one were males. Twenty-eight were carefully weighed, and 
gave an average of 7} lbs. each« Eighteen of the thirty- 
one women were primiparae* 

The time in labour may be given as follows : — Labours 
induced, 2 ; six hours or under, 2 ; seven to twelve hours, 
5 ; thirteen to eighteen hours, 4 ; nineteen to twenty-four 
hours, 7 ; twenty-five to thirty-five hours, 1 ; thirty-seven 
to forty-eight hours, 5 ; forty-nine to sixty hours, 2 ; 
sixty-one to seventy-two hours, 2 ; and four days, 1 =31. 
This record shows that promptness in action has very 
rarely been a virtue in the operations of the United States, 
as twenty-two of the thirty-one women were allowed to be 
in labour more than half a day, and one-half of these 
(eleven) over a whole day. 

The minimum conjugate measurement given by Morisani 
of Naples is 67 mm. ; we give it for this country at 70 mm., 
because of a greater average weight in the foetus. 

The fatal cases in the United States have been four ; 
and were in order Nos. 10, 14, 16, and 26. No. 10 was in 
labour twenty-five hours, taken to hospital with pulse of 
150, died in twelve hours. No. 14 in labour sixteen hours, 
died of septic peritonitis in twelve days, and believed to 
have been infected prior to the operation. No. 16 in labour 
twenty hours, taken to Maternity in emergency, on a cold 
rainy day, had been drinking whisky; died of double 



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PLBA FOB THE PRACTICE OF 8YMPHTSI0T0MY« 121 

pneumonia, attributed to exposure. No. 26 in labour three 
days before going to Maternity; died on tbe eleventh 
day from sepsis, originating in the sub-osseous wound. 

It will not be wondered at that there were nine foetal 
deaths. No. 1, labour lasted twenty-two hours, death in 
twenty-four hours, after long head pressure at inferior 
strait. No. 5, labour twenty-four hours, death on third 
day from meningeal haemorrhage. No. 10, labour twenty- 
five hours, death in seventeen hours, from injuries prior 
to admission to hospital. No. 14, labour sixteen hours, 
child stillborn. No. 17, labour fifty hours, child stillborn. 
No. 20, labour forty-eight hours, child stillborn. No. 22, 
labour twenty-one hours, death of child soon after delivery. 
No. 29, labour induced, c.v. 67 mm., death of child from 
injuries in delivery by the feet. No. 31, labour four days, 
child stillborn. Early operations should have saved nearly 
all but Case 29. 

Dr. Lewebs said that Dr. Harris, in sendiDg him the paper 
which had just been read, bad inquired what stopped the 
progress of symphysiotomy in England. It certainly seemed 
strange that so many cases should be reported from Italy, 
Prance, and America, and that nevertheless, so far as he knew, 
his own case, performed on February 12th, 1893, was the only 
case that had been published as having occurred in England 
since the revival of the operation. Dr. Harris had dealt with 
the subject from the historical point of view, and had divided 
it into two periods. The first, from 1777 to 1858, during which 
there were 150 symphysiotomies, and the second from 1866 to 
the present time. It was a significant fact that the last ten 
operations of those performed in the first period showed 
a maternal and foetal mortality of exactly 50 per cent. 
If one looked into the details of the cases belonging to the first 
period (which were given in a previous paper of Dr. Harris's), 
it was evident that some of the mortality was to be attributed 
to the operation having been performed in cases of extreme 
pelvic contraction with the object of making symphysiotomy a 
substitute for Csesarean section. Much of the mortalitpr also 
was no doubt due to the want of observance of antiseptic 
methods. It was well known that till recently the operation 
was condemned by writers on midwifery on the ground that it 
did not usefully increase the space available for the passage of 
the foetus, and this view was supported by experiments in the 
post-mortem room. It had, however, since been found that 



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12^ PLSA FOB THE PBACTICE OF STXPHTSIOTOICT. 

when similar 6X}>erimeiit8 were made on the bodies of women 
djin^ either in labour, or a few days after, division of the sym- 
physis did increase the space Tery considerably — ^the gaio in 
the conjugate being somewhere about three quarters of an 
inch. Dr. Lowers believed that the conditions essential to 
success in performing symphysiotomy were first that it should 
only be done in slight degrees of pelvic contraction where the 
pelvis was just too small to allow the passage of the fcBtus. It 
would be seen that this practically meant that symphysiotomy 
was an emei^ency operation, the special indication being failure 
to deliver with the forceps in a case when the pelvis was only 
slightly contracted. The second point necessary for success was 
a strict observance of antiseptic principles. The present mor- 
tality of symphysiotomy appeared to be about 7 per cent. 

Dr. Peter Hobbocks said that practically the question was, 
given a case where the child was alive, but where it was 
impossible to deliver it alive, which of the three measures, 
craniotomy, CsBsarean section, or symphysiotomy, should be 
adopted ? He considered that it was very unfair to compare 
the very best and lowest mortality in symphysiotomy and 
GsBsarean section, carried out with all modem cleanliness and 
antiseptic and aseptic precautions, with the mortality of crani- 
otomy in the past without such precautions. Indeed, he looked 
upon the mortality of craniotomy carried out skilfully and with 
modem asepsis to be nil so far as the mother was concerned. 
Again, he believed that the maternal mortality of GsBsarean 
section was leas than that of symphysiotomy, and certainly more 
of the children were saved. Hence on this ground he considered 
CsBsarean section was preferable to symphysiotomy. But there 
was another point to be considered besides the mortality, and 
that was the after-effects. In CsBsarean section there was a risk 
of ventral hemia, as after all abdominal sections. This might 
be lessened by more careful suturing. Then the patient might 
become pregnant again, and unless a miscarriage was induced, 
the uterus might rupture along the line of incision. He 
mentioned such a case in which sterility had been effected, so it 
was thought, by ligature of both Fallopian tubes. But two or 
three years later the patient conceived, and the uterus burst, 
and the child and a portion of the placenta escaped into the 
abdominal cavity ; laparotomy was performed, and the uterus 
was removed along with the child, placenta, and the uterine 
appenda^s. The specimen was now in the Guy's Hospital 
Museum, and it was interesting to note that one tube had been 
cut right through by the ligature, which lay halfway between 
the cut ends of the tube, glued to the parts by a little adhesive 
lymph. The cut ends of the tube were half an inch apart, and 
appeared to be quite sealed. The other tube had been bgatured, 
but the ligature looked as if it had been only just put on, and it 



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PLEA FOB THE FBACTICS OF 8TKPHTSI0T0MT. 123 

\ thouglit veiy likely that the lumen had not been sufficiently 
oecluded to prevent an ovum passing down to the uterus. He 
mentioned another case of Cesarean section where the tubes 
were tied and where the patient subsequently conceived ; a mis- 
carriage was induced, and she got all right. Of course, by 
adopting severer measures, such as removing a piece of the tube 
or even the ovaries, it might be possible to avoid this risk of 
future pregnancies. His own experience of symphysiotomy 
consisted in witnessing one case. His colleague. Dr. Galabin, 
operated. He confessed that he was greatly astonished to see 
the wide divergence of the cut surfaces of the symphysis. In 
one of Dr. Harris's cases he noticed that the distance was two 
and three quarter inches, and he should think it was quite as 
much as that in the case he saw himself. What the condition 
of the saero-iliac joints and ligaments was at the time he could 
only surmise. The pubes were brought together by means of a 
wire suture ; but altnough both mother and child survived, the 
mother has never been able to do any work since, and was, he 
had heard, at the present time in an infirmary, lying on her 
back most of the time. He wanted to know, therefore, whether 
this unfortunate sequela was at all common after symphysio- 
tomy, and whether it could be avoided in any way. One would 
expect that if the integrity of the bony arch of the pelvis were 
interfered with to such a degree as was implied by cutting 
through the symphysis pubis, there would be more or less im- 
pairment to the power of standing, walking, and working. In 
Dr. Lewers' case shown before this Society, the patient, altnoi^h 
able to walk, was not able to do her work as well as before the 
operation. On these grounds, therefore, he should recommend 
a patient under the conditions named to have craniotomy 
performed, or if she was desirous of having a living child, 
and was willing to take the extra risk, then he should recom- 
mend Csesarean section in preference to symphysiotomy. 

Dr. Griffith said the question Dr. lowers had felt himself 
unable to answer appeared to him (Dr. Griffith) to present no 
great difficulty. Why was symphysiotomy not more frequently 
performed in England P Because the operation was a very serious 
one for the patient, and those who Mvocated it most strongly 
had not succeeded in convincing them of the superiority of this 
grave operation over other methods of treatment involving far 
less danger to the mothers ; indeed, the extreme views of some 
who discarded the induction of premature labour and even the 
forceps for symphysiotomy, must produce a feeling against the 
legitimate but clearly limited use of the operation. Since the 
resuscitation of the oneration Dr. Griffith had been prepared to 
perform it in a suitable case, but though he had charge of about 
3000 cases yearly at St. Bartholomew's and at Queen Charlotte's 
Hospitals, he had had no case in which the necessary conditions 



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124 PLBA FOR THB PBACTICE OF 8YXFHT8IOT01CT, 

were present, namely, the patient in labour, a moderate degree 
of contraction (the conjugate about three inches), the foetus 
alive, and deUverf haviug failed to be effected with the for- 
ceps properly apptied« Fn>m his knowledge of the records of 
the operation, wnich as yet only gave the immediate results, he 
(Dr. Griffith) believed the risks of Csesarean section by a com- 
petent operator were to be preferred to those of svmphysiotomy. 
He very much hoped that Dr. Horrocks would examine and 
report to the Society the specimen to which he had referred, in 
which, after ligature of the oviducts during Csesarean section, 
intra-uterine pregnancy had followed. 

Dr. Leith Napibb agreed with Drs. Horrocks and Griffith 
in the general tenor of their remarks. He was at a loss to 
understand some of the arguments advanced by Dr. Lowers and 
Dr. Harris. With a pelvic conjugate of three inches it was often 
possible to deliver by forceps ; and in some cases, by performing 
version and bringing the small bimastoid end of the cephalic 
wedge first into the pelvis, delivery might be effected when 
forceps fikiled. It had been postulated that the minimum con- 
jugate measurement for sympnysiotomy was 2i inches. Between 
th& and natural or instrumental delivery was ^^mphysiotomy 
preferable to CflBsarean section ? In determining delivery by for- 
ceps we might require not only art but considerable vis afrowte ; 
strength as well as skill was frequently demanded. It had been 
advanced that an increased diameter of 2i inches could be gained 
by division of the symphysis. He accepted the fact as ad- 
duced by Dr. Horrocks, but thought it could only be explained 
by a total division of the ligaments. Usually, separation of 
the symphysis would only allow of from -^ inch to 1 inch of 
increased cuameter ; but if the ligament were divided they might 
have a cleft of 1^ inches to 2^ inches. Continental experience, 
with the exception of Pinard's, was hardly in accord with un- 
reserved acceptance of the operation. Except Zweifel, who 
admitted that fever followed most of his cases, no prominent 
German had endorsed Pinard's views. At any rate it was clear 
that up to the present the operation was not one to be employed 
in general practice. Such excellent results had been obtained 
recently from CsBsarean section that the call for symphysiotomy 
was not great. In the Soyal Maternity Charity of London, with 
an annual number of about 4000 deliveries, no case had required 
either of these proceedings since he had been on the staff. One 
had to estimate the after-condition of the patient as well as the 
immediate success, and so far experience had shown this to be 
better in CsBsarean sections than in cases subjected to division 
of the symphysis. 

The Pbbsidbnt thought that obstetrical science was much 
indebted to Dr. Harris for his laborious compilation, and to 
those gentlemen who had the boldness to practise new methods 



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PLEA FOR THE PRACTICE OP SYMPHYSIOTOMY. 125 

of deliveiy. and the candour to put the results before the pro- 
fession. He observed that the present mortality of symphysi- 
otomy, as shown by Dr. Harris s collection of American cases 
and the statistics of French operators, was about 10 per cent. 
Now Cflssarean section, in cases of pelvic contraction which was 
recognised during pregnancy, so that the operation was done at 
a selected time, with every needful preparation, and before the 
patient had had time to suffer from the effects of labour, was 
not attended with a higher mortality than this. The collectively 
high mortality of CsBsarean section was due to its being so often 
performed on patients already exhausted by protracted labour, 
injured, and infected with septic poison. Cnsarean section 
could be followed by sterilisation of the patient. The best way 
of doing this had not yet been established ; but by removal of 
the ovaries the patient could be undoubtedly saved from the 
risk of future pregnancies. If CsBsarean section were success- 
fully performed, tiiey knew of no ulterior ill effects from it. 
Symphysiotomy did not sterilise the patient. If accepted as the 
proper method of delivery in certain cases, it might be required 
in a case of the kind many times. No information whatever 
was before the profession showing whether the pubic symphysis 
could be repeatedly divided in the same patient in labour after 
labour, with good union following each time. The statistics at 
present before the profession were altogether silent as to the 
after histories. The patients recovered, and left the hospital 
able to stand and walk ; and that was all they knew of thenu 
Whether they were able to lift as much as liefore, to stand or 
walk as long as they previously could, they were not told. In 
the single case previously reported to the Society, although the 
patient could walk, yet her power of doing her household work 
was diminished. In another case reported, the springing 
asunder of the bones after division of the symphysis caused a 
laceration of the urethra. The frequency of accidents of this 
kind must be taken into account as well as the mortality. He 
was at present inclined to think that Csssarean section was 
preferable to symphysiotomy. 



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ON THE RELATION OF HEART DISEASE TO 
MENSTRUATION. 

By William J. Gow, M.D., M.R.C.P., 

PHTSICIAK-ACCOrCHEUB TV OHASOB OF 01TT-PATIBirT8, 8T. MABT'S HOSPITAL. 

(Received Jannaiy 4tb» 1894.) 

(AbstraeL) 

Pabticulajels with regard to menstruation are given of fifty 
cases. In twenty-eight the menstrual flow was unaltered. 
In seventeen the flow was absent or scantier than before. 
In five the flow was either more profuse or recurred more 
frequently than before. In no case was there good evidence 
that heart disease gave rise to severe menorrhagia. It would 
seem that either amenorrhoea or scanty menstruation was a far 
more common accompaniment of heart disease than menor- 
rhagia. 

A further analysis of these cases seems to point to the fact 
that heart disease leads to relative sterility, and also that it 
greatly increases the tendency to premature expulsion of the 
ovum. 

In conclusion, it is pointed out that a large number of women, 
suffering from valvular disease of the heart, pass safely through 
the period of pregnancy and labour. 

For convenience, these cases may be further analysed as 
follows : 

(1) Mitral stenosia (twenty-two cases) : 

In nine cases menstruation regular, and amount lost un- 
altered. 
In five cases menstruation regular but more scanty. 
In four cases there was amenorrhcaa. 
In four cases menstruation was either more frequent 
or more profuse. 



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OM THE BELATION OF HEART DISEASE TO MENSTRUATION. 127 

(2) Mitral incampetenee (fifteen cases) : 

In ten cases menstraation unaltered. 
In four cases meDstruation more scanty. 
In one case amenorrhoea. 

(3) Mitral tienoM and incompetence (seven cases) : 

In four cases menstruation unaltered. 

In one case menstruation more scanty. 

In one case amenorrhoea. 

In one case slightly increased menstrual loss. 

(4) Aortic incompetence and ohetruction (two cases) : 

In both cases menstruation unaltered. 

(5) Aortic and mitral incompetence (three cases). 

In all cases menstruation unaltered. 

(6) Aortic incompetence amd obstruction and mitral incompe- 

tence (one case) : 
Menstrual loss more scanty than before. 



The chief object of this paper is to answer two ques- 
tions: 

1st. Does organic heart disease modify the menstrual 
process ? 

2nd. If there is any such modification^ what is the 
nature of it f 

In collecting cases for this purpose some other collateral 
facts^ such as fertility and the liability to abortion or mis* 
carriage^ have been inquired rnto, and some reference 
will be made to these points at the end of the paper. 

For some time past I have taken notes of all cases of 
well-marked valvular disease in adult women which have 
come under my notice^ and the number collected amounts 
in all to fifty. Only one out of all these fifty cases had 
found her way into the Special Department for Diseases of 
Women (Case 44) ^ all the others being drawn from among 
either the promiscuous crowd of out-patients presenting 
themselves at the doors of a large general hospital^ or 
from the medical out-patient rooms or wards. It was for 
symptoms of an imperfectly compensated valve lesion that 
they came for help, and I believe that from such cases as 



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128 OK THB BELATIOK OF HEART DISEASE TO MENSTBUATIOK. 

these far more trustworthy conclusions can be drawn than 
if an attempt be made to estimate the relation of heart 
disease and menstruation from cases presenting themselves 
in any special department for the treatment of uterine 
disease. 

I may add that I approached the subject without bias^ 
and possessed only of a general impression that heart 
disease frequently caused monorrhagia. 

In the following table the main points of each case 
are given (Table I). 

It will be observed from this tabular statement 
that in five cases out of the total of fifty the menstrual 
loss was either more frequent or more profuse than before 
(Table I^ Cases 4, 15^ 18, 22, 43). In none of these cases, 
however, was the loss profuse enough to lead the patient 
to make any complaint of the condition at the time she 
came under observation. 

In Case 4 menstruation was regular until two months 
before she was first seen by me, but for the last two 
months she has had a loss of blood recurring every fort- 
night, but the amount lost is only moderate in quantity. 
This patient had had two attacks of rheumatic fever, the 
first twenty-three years ago, and the second eighteen 
years ago, and moreover she had suffered from shortness 
of breath for the last eight years. It is quite clear, there- 
fore, that the mitral stenosis from which she was suffering 
must have existed for a long time without in any way 
affecting the regularity or amount of the menstrual loss. 

In Case 15 the flow lasts three days and is not excessive, 
but the patient thinks that during the last year the amount 
lost is slightly greater than it was previous to that time. 

In Case 18 the periods have recurred at intervals vary- 
ing from two to six weeks since her confinement five years 
ago. The amount lost has also been more profuse during 
these five years than it was before. The flow generally 
lasts ten days, but is only profuse during the first two. 
She says that she has attended as an out-patient at one of 
the Metropolitan hospitals, for uterine disease. Inasmuch 



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THE RELATION OF HEART DISEASE TO MEKSTEUATIOK. 129 



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136 ON THE BELATION OF HEABT DISEASE TO KEN8TBUATI0N. 

as her symptoms dated from her last confinement, it is at 
least possible that the increased menstrual loss depended 
on troubles arising during the puerperal period, and were 
not directly due to the mitral stenosis from which she 
suffered. 

In Case 22 the patient also dates the increased quantity 
lost at the monthly period from her confinement four 
years before. The interval, however, which before this 
confinement was four weeks, now varies between five and 
six. 

In Case 43 the menstrual flow is regular every four 
weeks, lasting four to five days, but she thinks she has 
lost rather more at her periods during the last year than 
she did before. The amount lost^ however, is not excessive. 

The term monorrhagia could not, I think, fairly be 
applied to any of these five cases except to Case 22, who 
presumably was suffering from some form of uterine 
disease. 

In eleven cases the menstrual loss was more scanty than 
before^ and in six cases there was amenorrhcea which had 
existed for a longer or shorter period of time. In the 
two most severe cases of cardiac disease contained in the 
above table, amenorrhcea was present in each (Cases 
17 and 20). Both these patients suffered from mitral 
stenosis with great cardiac dilatation, enlargement of the 
liver, and dropsy, and in one of them tricuspid regurgita- 
tion was present. It is true that in the second of these 
cases (Case 20), though heart symptoms with dropsy had 
been prominent for many months, the amenorrhcea had 
only existed for three months, and previous to that time 
the menstrual loss had been normal. Thus it would seem 
that in advanced cases of mitral disease with great cardiac 
dilatation and general dropsy, menstruation ceases after a 
time. In the remaining twenty-eight cases the interval, 
duration, and amount of the menstrual loss were un- 
altered* 

It will thus be seen that out of fifty cases, in twenty- 
eight menstruation was unaltered ; in seventeen the flow 



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OK THE RELATION OF HEART DISEASE TO MENSTRUATION* 137 

was absent or scantier than before ; in five the flow was 
more profuse or more frequent than before. 

In the two cases where the aortic valves alone were in- 
volved it will be noticed that menstruation was unaffected. 

Judging from statements made in text-books^ there 
appears to be a prevailing opinion that mitral disease is a 
cause of menorrhagia. Prom the history of the patients 
that have come under my observation it will be seen that 
amenorrhoea or scanty menstruation occurs much more 
often than any increase in the menstrual loss (in the pro- 
portion of 17 to 5), and among all the fifty cases there was 
only one well-marked case of menorrhagia. I have no 
doubt that cases do occasionally present themselves in the 
out-patient department for diseases of women^ suffering 
from menorrhagia complicated by the presence of organic 
mitral disease^ but how far the latter is the cause of the 
former is open to some doubt. It must be remembered 
that miscarriages are somewhat frequent among patients 
suffering from mitral disease^ and the haemorrhage of 
which the patients complain may be the result of recent 
abortion or endometritis following it, and not directly 
dependent on the heart lesion. The fact that in more 
than half the cases the menstruation was unaltered would 
certainly seem to bear out this suggestion. 

Within the last few months I have seen two women^ 
both the subject of heart disease — one of mitral stenosis 
and one of mitral regurgitation. Both of these women 
came complaining of loss of blood, but on examination it 
was found that one of them was suffering from advanced 
carcinoma of the cervix and the other from a large uterine 
fibroid, which was subsequently removed by abdominal 
hysterectomy. Among the cases recorded in the above 
table, in all those who were suffering from great cardiac 
dilatation with enlargement of the liver and dropsy, the 
menstrual flow was unaltered or it was absent. 

This is a matter of considerable interest, because there 
can be little doubt that in such cases there must be passive 
congestion of the pelvic viscera, and we have therefore an 



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138 ON THE RELATION OP HEART DISEASE TO MENSTRUATION. 

opportunity of observing what are the symptoms, if any, of 
passive uterine congestion. If we take the cases where 
cardiac dilatation is most advanced, and consequently where 
passive congestion is most marked, as, e. g., Cases 17, 20, 
and 42, we see that prolonged passive uterine congestion 
leads to amenorrhoea, though menstruation may persist 
unaltered for some time in spite of the congestion. In 
Gases 17 and 20 it is noted that while the menstrual loss 
persisted, it was unaccompanied by pain. Congestion of 
the uterus is a phrase less often heard now-a-days than 
formerly, but from a consideration of such cases as these 
there appears to be no reason to believe that passive con- 
gestion of the uterus, per «0, causes any symptoms at all 
except perhaps amenorrhoea. Although there is a consider- 
able amount of literature on the subject of the relation of 
heart disease to pregnancy, I have not been able to find 
any bearing directly on the subject of heart disease and 
menstruation. 

In a pamphlet by Berthiot entitled ' Grossesse et Mala- 
dies du Coeur,' published in 1876, he relates a large 
number of cases of pregnancy and labour complicated by 
heart disease, and in seven of them states incidentally the 
condition of the menstrual function previous to pregnancy. 

Of these seven, four suffered from mitral stenosis and 
incompetence and three from mitral incompetence alone. 
In four of these cases the menstrual flow was said to be 
regular and normal in amount, whilst in the three other 
cases it was irregular and scanty, the interval being more 
than twenty-eight days. It will be noted that none of 
them had suffered from monorrhagia, which supports the 
results obtained from my own series of cases. 

There is another point which is perhaps worth noting, 
and that is the frequency of amenorrhoea during the 
attacks of rheumatic fever. In eight cases where attention 
was paid to this point, it was found that in seven of them 
menstruation ceased during the rheumatic attack, but in 
one it continued to recur regularly although the joint pains 
lasted for five months. 



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ON THX RELATION OF HEABT DISEASE TO MENSTRUATION. 139 

By a consideration of these cases we may, I think, 
also learn something concerning the bearing of heart 
disease upon fertility and the liability to abortion. I am 
fully aware that the histories of these cases do not allow 
of very accurate statements being made on this point, and 
that great caution is necessary in drawing conclusions. 
The great diflSculty lies in the fact that it is almost impos- 
sible to be absolutely certain when the valves were first 
attacked, and therefore whether at the time of marriage 
heart disease was or was not present. 

To eliminate as far as possible this source of error, I 
have selected twelve cases from Table I of married women 
who have had rheumatic fever on one or more occasions 
either before or immediately after marriage, and who, 
moreover, have had no attacks since. In these cases I 
think we may fairly assume that the valve lesion dated from 
the attack of rheumatic fever, and that therefore all such 
patients may, after this date, be considered to be suffering 
from valvular disease. The number of cases is unfor- 
tunately too small to make the deductions drawn from 
them of much value, but none of the other of the fifty 
cases fulfilled the conditions laid down above (Table 
H). 

All the patients arranged in this table were the 
subjects of mitral disease, and at the time they came 
under observation were suffering from cardiac symptoms 
due to an imperfectly compensated valve lesion. 

Among these twelve women the total number of chil- 
dren bom was fourteen, and the total number of miscarriages 
was ten. 

Two of the patients exhibited absolute sterility, and two 
others had miscarriages but no full-time children. In this 
country the normal proportion of sterile to non-sterile 
marriages appears to be 1 in 10, so that the fertility of 
women with mitral disease would seem to be slightly less 
than normal. It will be noticed, however, that some of 
the patients had only been married a comparatively short 
time, but still the number of pregnancies is small, and 



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140 ON THE RELATION OF HEART DISEASE TO MENSTRUATION. 






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OK THE RELATION OF HEART DISEASE TO MENSTRUATION. 141 

would snggest that mitral disease led to some degree of 
relative sterility. 

The number of years of married life among these twelve 
women was nearly seventy-four (73'5), or an average of 
six and one-third years each. The number of pregnancies 
was twenty-four (fourteen children and ten miscarriages), 
or an average of two each. 

Of the ten women who had been pregnant five had had 
no miscarriages, while the other five had miscarried on one 
or more occasions. It is stated by Galabin that the pro* 
portion of miscarriages to full-time deliveries is as 1 to 5. 
Among these twelve women however, the proportion of 
miscarriages to full-time deliveries is as 10 to 14, — that is 
to say, among these twelve women the proportion of mis- 
carriages to full-time deliveries was 3'57 times greater 
than usual. 

The existence of mitral disease seems, therefore, to 
greatly increase the tendency to premature expulsion of 
the ovum. 

Though, as is well known, serious accidents may happen 
before, during, or after delivery to women suffering from 
heart disease, in these particular cases there was no 
history of any serious trouble experienced by the patients 
either while pregnant or during or after labour. In only 
one of the cases was hssmoptysis noted during pregnancy. 
It is not my purpose, however, to enter into any discus- 
sion on this point, as the histories elicited from the patients 
do not furnish sufficiently complete data from which to 
work. If they show anything they show that women who 
have valvular disease may pass safely through the period 
of gestation and parturition and escape all the well- 
known accidents which have been so often described. 
Since writing the above, I have read a paper by Dr. Ch, 
Vinay published in the 'Archives de Tocologie et de Gyn6- 
cologie ' for November, 1893, which further illustrates the 
tolerance which many women who are the subjects of 
valvular disease of the heart exhibit to pregnancy and 
delivery. During 1891 and 1892 he auscultated all 



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142 ON THE BELATIOK OF HEART DISEASE TO MENSTRUATION. 

patients admitted into the maternity hospital^ 1700 in 
number, and detected valvular disease in twenty-nine 
cases. In twenty-four of these cases there was either 
mitral stenosis or mitral incompetence or both combined. 
In one case there was aortic incompetence and in one case 
tricuspid incompetence, whilst in the remaining three 
cases there was combined aortic and mitral incompetence. 

In only four of these cases was there any heart trouble 
during pregnancy or labour, and in only one of these 
cases was it at all serious. This was a case of mitral 
stenosis and regurgitation, and the patient suffered from 
dyspnoea, cyanosis, and oedema of the legs. She was 
delivered of twins, the delivery being followed by rather 
free post-partum haemorrhage. She, however, made a 
good recovery. 

The fact that the great majority of women who suflfer 
from valvular disease of the heart pass safely through the 
period of pregnancy and labour is important, and is apt 
to be overlooked unless systematic examination of the 
heart be made in all cases. 



Dr. John Phillips said the paper had much interested him, 
owing to his having for some time been engaged in attempting 
to ascertain the truth of the assertion that women with heart 
disease suffered from menorrhagia. No reference was made to 
the subject in the literature of the last twenty years, and e^en 
the elaborate papers of MacDonald, Porak, Schlayer, Yinaj* 
and Leyden upon heart disease and pregnancy only occasionally 
alluded to the menstrual history of patients mentioned by those 
authors. He had examined the hearts of 656 women con- 
secutively, whose ages varied between eighteen and forty-four, 
in the out-patient room at King's College Hospital. In this 
series only sixty-nine presented cardiac murmurs of any kind, 
and fifty-two of these were evidently annmic, and therefore 
inadmissible, leaving seventeen cases of undoubted organic 
disease. Of the seventeen, eleven applied during pregnancy for 
relief from symptoms due to some compensatory disturbance, 
and nine of these were followed up and their menstrual history 
reported upon. The remaining six patients were nullipara, 
four suffering from mitral disease, and two from aortic obstruc- 
tion. In none of the fifteen cases was there at any menstrual 
epoch sufficient hsemorrhage to be termed menorrhagia* In the 



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OK THE BELATIOK OF HEAHT DISEASE TO MENSTRUATION. 148 

majority of tliem there was a tendency to amenorrlicBa, and in 
the two aortic cases the patients attended in consequence of 
amenorrhooa and breathlessness. Cases in private practice 
observed by Dr. Phillips entirely supported the idea' of men- 
struation being rather diminished than increased in amount in 
women with cardiac disease. He quite agreed with Dr. Gow in 
all his conclusions, with the exception that he thought perhaps 
a woman conceived just as readily with a damaged heart as 
with a healthy one. The tendency to abortion in women with 
cardiac disease was undoubted, but this scarcely came within 
the scope of the paper under discussion. 

Dr. Peteb Hobboces recognised the value of the paper, but 
he pointed out that there was another method of approaching 
the subject, and one which offered a far better hope of 
obtaining accurate knowledge, and that was a careful com- 
parison of the. menstrual history of a patient with the condition 
of her heart as found post-mortem. And here he would make 
an appeal to his surgical and medical confreres that they would 
insist on a careful record of a patient's menstrual history being 
included in every clinical report as a matter of routine. It was 
very disappointing when an interesting condition of things was 
found post-mortem, to discover in the clinical reports absolutely 
no mention of the menstrual history, or at most a very meagre 
account. He pointed out that nearly all the cases brought 
forward by Dr. (Jow were said to be suffering from mitral 
stenosis ; obviously the first effect of this would be on the lungs, 
and this was found to be so, as they suffered from shortness of 
breath, bronchitis, &c. Now in order that the uterus and pelvic 
viscera should be affected it was necessary for the cardiac lesion 
to produce not only lung symptoms but also symptoms reveal- 
ing tricuspid incompetence, such as dropsy or oedema. In only 
six out of the fifty cases was this sign present^ namely in Nos. 
11, 17, 20, 82, 41, and 49. Hence it might be argued Uiat it was 
not surprising that menstruation had not been profuse. But in 
those six cases menstruation was either absent or scanty, or not 
excessive. Now the text-books taught that heart diseases, 

rking broadly, were a cause of menorrhagia. He believed 
this statement was founded upon reasoning by analogy, 
namely, that because heart disease produced congestion of 
various viscera, therefore it would cause congestion of the pelvic 
viscera, and so menorrhagia would probably result. But Dr. 
Cow's cases tended to quite an opposite conclusion, and he 
bdieved Dr. Gk)w was right. He then detailed several cases in 
which careful j^st-mortem examinations had revealed extensive 
disease, including aortic, mitral, and tricuspid valvular lesions, 
in which the periods had been absent or scanty, or at aU events 
not altered since the period when the heart disease had pre- 
sumably begun. If the circulation were impeded on the venous 



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144 OK THE RELATION OF HEART DISEASE TO MEKSTBUATIOK. 

side one would have expected that menstruation would have 
been lessened or stopped, owin^ to the deficient oxygenation of 
the blood in the ovaries. But what was wanted were the facts of 
the case, and he thought that thej were in favour of Dr. Gow's 
conclusioDS. 

The President desired to call attention to the admirable 
method of Dr. Oow's research. The same subject had been treated 
of in a paper read to the Eoyal Medical and Chirurgical Society 
recently. The author of that paper had investigated the ques- 
tion at a women's hospital. He took patients who came to the 
hospital because they supposedHhat something was wrong with 
their reproductive organs, and ascertained the frequency of 
cardiac disease in them. Such a method would show a greater 
frequency of functional disturbances of the genital organs asso- 
ciated with heart disease than was actually the case. Dr. Gk>w, 
on the other hand, took patients with heart disease, and inquired 
into the frequency of menstrual disturbance in them. This was a 
method the result of which mi^ht be depended on. Dr. Oow's 
research filled up a blank space in their knowledge of menstrual 
disturbances as well as of sterility and abortion. He (the Presi- 
dent) had made some observations on the effect of venous conges- 
tion from heart, lung, and liver diseases on menstruation, and his 
results in the main agreed with those of Dr. Gow. Dr. Gow's 
statement that text-books said that heart disease caused uterine 
hsemorrhaee he believed was correct as to most of them ; but 
the clinical lectures of the late Dr. Matthews Duncan was an 
exception — his book did not contain this error. 

Dr. Griffith had seen one case which he believed to be an 
exception to the rule stated by Dr. Gow. A tall, well-made servant 
about twenty-five years of age came as an out-patient to the 
Samaritan Hospital some years ago, suffering from menorrhagia, 
profuse and lasting about ten days ; being single, the usual 
remedies were tried withoat a vaginal examination, and without 
benefit. Something in the history of the case led him to exa- 
mine the heart, and mitral regurgitation was found. In conse- 
quence of this no vaginal examination was made, and the use of 
ergot, &c., was stopped. Soon after this she married and went to 
live at Dover, and the doctor who attended her was good enough 
to write and inform him that she had two children, her heart 
trouble getting worse. The case was one he hesitated to bring 
forward for two reasons : in the first place he had to depend on 
his recollection of the circumstances, which occurred some years 
ago ; secondly, he had not, for the reasons stated, made any 
examination of the uterus. 



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APEIL 4th, 1894. 

G. Ebnebt Hsbmak, M.B., President, in tlie Chair. 

I^resent — 53 Fellows and 4 visitors. 

Books were presented by Sir H. W. Acland, Dr. Muret, 
Messrs. Wright and Co., and tlie Soci^te des Sciences 
M^dicales de Lyon. 

George A. H. C. Berkeley, B.A., M.B., B.C.Cantab. ; 
Woodley D. Betenson, L.E.C.P.Lond. ; David Brown, 
M.D.Lond. ; Lennard Cutler, L.E.C.P.Lond. ; Jokn W. 
Dickson, B.A., M.B., B.Q.Cantab. ; David L. Hamilton, 
L.E.C.P.Ed. (Great Missenden) ; Wilfrid E. Hudleston, 
L.B.C.P.Lond. ; James P. James, L.E.C.P.I. ; Sidney H. 
Lee, B.A.,M.B., B.C.Cantab. ; Edgar Nicholson, M.E.C.S. ; 
and Thomas G. Stevens, M.D., B.S.Lond., were admitted 
Fellows of the Society. 

Hedley Coward Bartlett, L.E.C.P.Lond. (Saffron 
Walden) ; Henry W. Drew, F.R.C.S. (Croydon) ; Charles 
Herbert Fazan, L.E.C.P.Lond. (Wadhurst) ; Charles 
B. M. Green, L.E.C.P.Lond. (Calcutta) ; Edward Home, 
M.E.C.S. (Wallingford) ; Herbert J. Ilott, M.D.Aber. 
(Bromley, Kent) ; Albert Stanley McCausland, M.D.Brux. 
(Swanage) ; John McOscar, L.B.CP.Lond. (Watlington) ; 
William Henry Mondelet, M.D. (Brighton) ; Clement 
Pound, L.B.C.P.Lond. (Odiham) ; Horace Savory, M.A., 
M.B., B.C.Cantab. (Hertford) ; Archdale Lloyd Sharpin, 
L.E.C.P.Lond. (Bedford) ; and Montague Tench, M.D.Bruz, 
(Gt. Dunmow), were declared admitted. 

VOL. XXXVI. 10 



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146 F(ETUS AND PLACENTA KEMOVBD BY LAPAROTOMY. 

The following gentlemen were proposed for election : — 
Eeginald T. H. Bodilly, L.R.C.P.Lond. (South Woodford) ; 
Andrew Bradford, M.D., CM. Toronto (Lanark, Ontario) ; 
and Charles Ernest Goddard, L.R.C.P.Lond. (Wembley). 



FOSTUS AND PLACENTA REMOVED BY LAPA- 
ROTOMY, FROM A CASE OF EXTRA-UTERINE 
GESTATION. 

By William Doncan, M.D. 

The patient, aged 34, multipara, was admitted to the 
Middlesex Hospital on February 14th, 1894, with the fol- 
lowing history. 

Her last child was born in November, 1889, since then 
the periods were quite regular until November, 1893, when 
that period was missed altogether. A month later she 
had a show at the proper time, and the loss, which was of a 
brownish colour, had continued on and off until her admis- 
sion. A few days before Christmas, when in bed, she was 
seized with a severe pain in the back, and fainted away for 
ten minutes. She sent for a doctor, who said she had in- 
flammation, and ordered hot fomentations. Since then, up 
to her admission to hospital, she has been in bed with pain 
and irregular discharge of blood. 

On admission there is found in the lower abdomen an 
irregular swelling, separated in the middle line by a 
depression ; the tumour on the left side feels like a some- 
what enlarged uterus ; that on the right side is larger, 
xnore elastic, and less defined. 

Auscultation reveals nothing. The breasts are tender, 
and some secretion can be squeezed out. 
, F&r vaginam. — The os uteri was found to be pushed 
forward and high up by a large cystic swelling, filling up 
the pouch of Douglas and depressing the vaginal roof. 
Extra-uterine pregnancy was diagnosed, and abdonunal 



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FCETOS AND PLACENTA REMOVED BY LAPAROTOMY. 147 

section was performed on March 22nd. When the abdo- 
men was opened, the tumour on the right side consisted of 
the placenta with the exception of a small portion at the 
upper part ; this was incised, when amniotic fluid gushed 
out ; two fingers of the left hand were inserted, and the 
foetus seized and extracted by the feet. The passage of the 
head tore the placental tissue, and there was free bleeding 
until the vessels were seized with large clamp forceps^ An 
attempt was then made to stitch the edge of the sac to 
the parietal peritoneum, but sudden and profuse haemor- 
rhage took place from the deeper parts of the sac, sp that 
Dr. Duncan decided at once to peel off the placenta ; this 
he did whilst the abdominal aorta was compressed by 
Mr. Hulke. The placenta was removed without difficulty, 
and then the sac could be seen passing down to the bottom 
of the pelvic cavity ; it was firmly stuffed with iodoform 
gauze, six yards in all being used; no further bleeding 
occurred. The edge of the sac was fastened to the 
parietal peritoneum, and the abdominal wound above the 
sac closed in the usual way. Altogether the patient did 
not lose more blood than most women do at an ordinary 
confinement. 

From the time of the operation the patient^ s pulse be- 
came extremely rapid ; her temperature rose to 105® on 
March 25th ; she was delirious, and died exhausted on the 
sixth day after the operation. The gauze stuffing the 
sac was removed on the third, day, and was only just 
slightly blood-stained. 

Post mortem there was only a very slight amount of 
peritonitis, where the sac was stitched to the abdominal 
wall. 

Dr. Duncan said he considered the patient died from 
iodoform poisoning, and that in another case he would stuff 
the sac with kreolin gauze. 

Dr. Champkbts said that, while congratulating Dr. Duncan 
on his escape from serious hemorrhage in removing the placenta, 
be hoped that Fellows would not go away with the idea that this 
was a safe proceeding. On the contrary, in many recorded 



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148 FCETUS AND PLACENTA REMOVED BY LAPABOTOHY, 

cases the bleeding had proved uncontrollable, and the patients 
had lost their lives. 

Mr. Alban Doban asked Dr. I>uncan if the pulse was very 
high in his case of suspected iodoform poisoning. This sym- 
ptom was noted by Slaviansky, Elischer, and others, many 
years ago (• Centralblatt f. Chirurg.,' vol. xiv, 1887, p. 234). 
Mr. Doran had observed high pulse in two cases of aldominal 
section under his own care, where iodoform had been freely 
applied to the abdominal wound, and in a third case where 
iodoform had been freely stuffed into a large pelvic abscess. The 
pulse grew slower when the iodoform was left off, but all three 
cases were convalescent, and the diminished rate of the pulse 
might be in great part due to the increased strength of the 
patient. 

The Pbesidbnt asked if it was necessary to stitch the sac to 
the abdominal walls. This was quite useless unless it was done 
accurately and thoroughly, and to do this was tedious, and 
might be difficult. He thought it was unnecessary ; if the sac 
were plugged with gauze, the gauze was soon shut off by lymph 
from the rest of the abdominal cavity. In Dr. Duncan's case it 
seemed as if it were the dragging on the sac during the stitching 
that caused the h»morrhage. If so, the stitching increased the 
danger. He had seen one case of iodoform poisoning from 
stuffing a bleeding pocket in the pelvis with iodoform gauze ; 
there was extreme rapidity of the pulse, delirium, involuntary 
passage of urine and fseces, but no vomiting or abdominal 
tenderness or distension. After removal of the gauze the 
patient quickly improved, and got quite well. Had he a case 
like Dr. Duncan's with symptoms of iodoform poisoning during 
life, and signs of peritonitis on post-mortem examination, he 
should attribute the death to the peritonitis, and not to the 
iodoform poisoning. 

Dr. Ettles asked Dr. Duncan as to whether there was — 1. Dis« 
chromatopsia. 2. Albuminuria. 3. The " iodoform " delirium 
present in his case. In a case of partial iodoform poisoning 
which had come under his notice, dischromatox>sia was a marked 
symptom, and if it were generally present in such cases it would 
be useful as a monitor of impending poisoning. 

Dr. Fenton requested Dr. Ettles to explain the meaning of 
the term used. 

Dr. Ettles said that by dischromatopsia he understood an 
alteration or aberration of the patient's colour sense, due usually 
to toxic causes, the chief subjective sensation beiug that 
external objects had a dominant colouring, usually yellowish, 
but often red (erythropsia), and having a coloured outline. 

Dr. Duncan in reply said that, notwithstanding the risks of 
removing the placenta at the time of operation, he felt disposed 
to treat his next case in the same way. He could not agree 



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HYPBRTROPHIED NYMPHiB AND CLITORIS. 149 

with the President with regard to its not being important to 
stitch the edge of the sac to the parietal peritoneum, and he 
thought a little time was well spent in the careful coaptation 
of the two. He was confident, as there was only a trace of peri- 
tonitis found post mortem, that the patient died of iodoform 
poisoning. The patient had during the whole time she lived a 
very rapid pulse (150 to 160) ; there was also the peculiar 
delirium, but unfortunately the presence of dischromatopsia was 
not looked for. 



CASE OF CYCLOPS. 

Shown by Dr. Ettles. 

A COMMITTBB, Consisting of Drs. Giles, Tate, and Ettles, 
was appointed to report on this specimen. 



HYPBRTROPHIED NYMPHS AND CLITORIS. 

By William Duncan, M.D. 

Dr. William Doncan showed this specimen on January 
3rd, 1894 (p. 3), which he had removed by the knife from 
a single woman, aged 25, who in the summer of 1891 was 
a patient in the Lock Hospital, with an abscess in the left 
groin and left labium, together with a vaginal discharge. 
No history of syphilis could be obtained, but there was a 
small patch of psoriasis on the lower abdomen, and also a 
scar in front and on the under surface of the right half 
of the tongue, where the patient said she had a small sore 
place. There was marked enlargement of the vulva, chiefly 
affecting the labia minora, which appeared to be continued 
down to the posterior part of the vulva, where they met on 
the perineum. On their inner surface were several ex- 
cavated ulcers with irregular margins. The hypertrophied 
nymphee were of a whitish colour. 



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150 HYPERTEOPHIED NYMPHJE AND CLITORIS. 

On December 18tli, the patient being anaesthetised and 
in the lithotomy position, the whole of the nymphse and 
the clitoris were removed by the knife ; the spouting 
vessels were tied with fine catgut, and the edges of the 
vaginal mucous membrane united with the skin edges. 
The margin of the urethral orifice was united with the 
adjacent skin. 

Suhaequent progress, — Owing to the unhealthy condition 
of the parts there was failure of primary union in great 
part of the incision, and healing took place by granula- 
tion and cicatrisation. 

Mr. Alban Doban believed that many diseases which de- 
formed the vulva were originally akin to common skin affections, 
eczema, psoriasis, &c. The muco-cutaneous portion of the 
vtdva was first attacked, and the constant irritation from urine, 
sme^a, and vaginal mucus modified the eruption ; ultimately 
the labia minora became cedematous or otherwise morbid. Many 
cases described as *' lupus minimus " seemed to him to be eczema 
around the meatus in women who passed urine loaded with 
urates. 



Report on Dr. Duncan^s Specimen of Hypertrophied Vulva. 
Shown January Zrd, 1894 [p. 3), and described above. 

The tumour consists of the two labia minora, clitoris, 
and part of mons Veneris. The two labia are greatly 
hypertrophied, measuring four inches wide, two inches deep, 
and one inch thick ; the surface is irregular and corru- 
gated. On the inner surface of the right labium and on 
both surfaces of the left are a number of shallow punched- 
out ulcers, varying in size from one eighth to half an inch 
in diameter. There is no induration around the ulcers. 
There are several similar ulcers around the clitoris. 

A microscopical vertical section through one of the 
ulcers shows the squamous epithelium somewhat irregu- 
larly thickened. Over the situation of the ulcer the 
epithelium is entirely absent, and the floor of the ulcer 
has an irregular ragged appearance, with small round- 
celled infiltration of an inflammatory nature. 



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HYPEBTBOFHIED KTHPHJi: AND CLITORIS. 151 

In the deeper part of the section, away from the ulcer, 
the squamous epithelium is seen to dip down. There are 
separate islets of squamous epithelium encapsuled, and 
with a small-celled infiltration round. None of these 
separate islets are arranged ifi the form of " nests.^^ 

p. horrocks. 

William Duncan. 

Walter W. H. Tate. 



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152 



ON CASES OP ASSOCIATED PAROVARIAN AND 
VAGINAL CYSTS, FORMED FROM A DIS- 
TENDED GARTNER'S DUCT. 

By Amand Routh, M.D., B.S., M.R.C.P. 

(BecttTed January 23rd, 1894.) 

{Abstract) 

Details of three cases of the above are giyen, and also of 
two analogous cases of patency of the whole length of the duct, 
with an anterior opening allowing free discharge, and thus 
preventing distension of the dact along its course. 

Comparison is drawn between such cases and those of dis- 
tended but imperforate MuUer's ducts. 

Evidence adduced from these cases is thought to establish, or 
at least to render plausible, the following propositions : 

1. That Gartner's duct can be traced in some cases in the 
adult female from the parovarium to the vestibulum vu]v», 
ending just beneath and slightly to one side of the urethral 
orifice. 

2. Homology tends to show that Max Schtiller's glands are 
diverticula of (Jartner^s ducts, just as the vesiculso seminales 
are diverticula of the vasa deferentia. Some evidence is given 
that Skene's ducts are not necessarily identical with the anterior 
termination of Ghurtner^s ducts (as most of those who have 
traced Gartner's duct to the vestibule have thought), but that 
Skene's ducts lead directly and solely from Max SchuUer's 
urethral glands, Ckurtner's ducts being continued to the vesti- 
bule, behind, but parallel to, Skene's ducts. 

3. That Gartner's duct, if patent, may become distended at 
any part of its course, constituting a variety of parovarian cyst 



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A880CIATKD PABOVABIAN AND VAGINAL CY8T8. 158 

if the disteDsion be in the broad ligament portion, and a 
vaginal cyst if the distension be in the yaginal portion. The 
cases described are instances of the association of both of these 
cysts, owing to simultaneous patency and distension of both 
portions of the duct. 

4. Attention is drawn to these cases as affording explanations 
of some obscure cases of profuse watery discharge from the 
▼agiua, not coming from the uterus or bladder. 

5. The question of treatment is also approached, and the 
opinion is expressed that where the whole duct is distended the 
vaginal part of the cyst may be laid open as far as the base of 
the broad ligament, and the broad ligament portion encouraged 
to contract and close up. 

The following cases are examples of a condition pro- 
bably very rare, namely, a vaginal cyst conmiunicating 
with a cyst between the layers of the broad ligament, and 
the explanation offered in this paper is that these asso- 
ciated cysts are the result of distension of a persistent 
Gartner's duct as it passes through both structures. 

Case 1. — Miss C. C — ^ aged 25, first saw me in 1889 
for coccygodynia and bearing down, due to pelvic conges- 
tion. She improved rapidly, but over-walked herself in 
January, 1890, and for a few weeks suffered as before. 
Two years and a half afterwards, November, 1892, she 
consulted me again for pain over the right ovarian region, 
and a profuse yellow watery discharge^ which was occa- 
sionally offensive. Walking caused great pain down the 
right leg and in the right side. The abdomen was some- 
what distended, and the muscles resistent over the right 
half of the abdomen. Per vaginam the uterus was mobile, 
but pushed over to the left by a somewhat elastic mass on 
the right side of the pelvis, situated apparently between 
the layers of the broad ligament. Bimanually this mass 
could be felt to be partly mobile, elastic, tender, and sepa- 
rate from the uterus, which by means of the sound could 
be moved to some extent independently of the broad liga- 
ment tumour. 



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154 ASSOCIATED PAROVARIAN AND VAGINAL CYSTS. 

In the vaginal wall, running from the base of the right 
broad ligament, starting from a spot slightly to the right 
side of the cervix, there was an elastic ridge, somewhat 
irregular in outline, which passed forwards and towards 
the middle line, becoming lost a little to the right of the 
urethra, about three-quarters of an inch behind the base 
of the vestibule. I could not find out where the dis- 
charge came from, though I noticed that the upper part 
of the vagina was free from discharge whilst the vulvar 
orifice was always moist, and soiled by a somewhat viscid, 
yellowish, offensive secretion. 

A fortnight later the patient suffered severe throbbing 
pain, and the temperature rose nightly to 101° or 102° F. 
The vaginal ridge had then become larger, tenser, and 
more elastic, and evidently contained fluid reaching very 
nearly to the vaginal outlet in the middle line of the 
vaginal roof. 

In a few days the portion of the vaginal cyst near the 
cervix was found to be more swollen, being about the size 
of a thumb, but the rest of the vaginal ridge seemed to 
consist of several cysts, apparently intercommunicating. 
There seemed also to be definite communication between 
the vaginal cyst and the broad ligament tumour, from the 
fact that pressure upon the vaginal cyst caused its con- 
tents to pass backwards, whilst straining or coughing 
immediately refilled it. 

The patient went into a nursing home, and was exa- 
mined under ether. The vaginal cyst was then found to 
be collapsed along its whole length ; the broad ligament 
tumour was very distinctly made out, and was thought to 
be a broad ligament parovarian cyst, the vaginal cyst 
being presumably a patent Gartner's duct communicating 
with the cyst cavity. At the end of the examination, as 
the patient was regaining consciousness, she coughed, and 
bore strongly down, causing a quantity of yellowish offen- 
sive pus to come out of a minute hole not previously seen, 
just beneath and to the right of the urethral orifice at the 
base of the vestibule. A small probe passed down this 



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ASSOCIATED PAROVARIAN AND VAGINAL CYSTS. 155 

abnormal orifice for three-quarters of an inch, and the 
passage was laid open as a rectal fistula would be. The 
openings of Skene's ducts just within the urethral orifice 
were quite perceptible. 

I then opened the main vaginal cyst about 2 inches 
up the vagina, but was not able to pass a probe for any 
distance either backwards or forwards. 

Offensive pus continued for some days to come away 
from both of these places, but mainly from the anterior 
orifice ; indeed, I do not think I really opened the main 
cyst posteriorly on the first occasion. A few days later I 
succeeded in passing a probe along the whole canal fi^om 
the anterior orifice, and subsequently a director ; and, 
under ether, freely laid open the vaginal cyst by means of 
a Paquelin's cautery knife, letting out much pus, which 
welled freely out of the upper end of the incision at the 
base of the broad ligament. 

The duct thus laid open was lined by smooth membrane, 
but no microscopic examination was made. 

A sound passed into this upper opening near the cervix 
went a distance of five inches upwards and outwards, and 
was evidently inside a cyst cavity in the broad ligament. 

The opening was enlarged to admit the finger, which 
could be passed into the cyst behind the vagina, and could 
make out that the lining membrane was smooth, and that 
the cyst was between the layers of the broad ligament. 
Per rectum the examining finger passed well behind the 
cyst cavity, and could then detect a sound passed into the 
parovarian cyst from the vagina. The cavity was washed 
out with iodised water, and a drainage tube inserted. 

For nearly five weeks the purulent fluid continued to 
come away, speedily losing its offensive odour and becom- 
ing daily more watery, and at the upper end the sides of 
the vaginal cyst tended to unite again over the drainage 
tube, which was gradually shortened and finally removed, 
leaving a canal in the vaginal wall about an inch long 
(March, 1893) on the right side of the cervix. 

November 7th, 1893.^— A rut or trough is to be felt in 



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156 ASSOCIATED PABOVABIAK AND VAGINAL CTSTS. 

the vaginal wall to the right of the vaginal portion, leading 
into a short canal an inch long. The canal now only 
admits a large sound, and ends in a cul-de-sac. It is 
lined by a bright red membrane. The uterus lies in its 
central position, and nothing abnormal can be felt in the 
right broad ligament region. The patient feels perfectly 
well. 

This is believed to have been a case of distended 
Grartner's duct, where the contents finally suppurated. It 
is probable that at first the vaginal part of the duct was 
impervious, but had become gradually opened up by the 
pressure of the contents of the distended portion in the 
broad ligament where the pain first began. 

I have only been able to find two other cases of asso- 
ciated broad ligament and vaginal cyst, one described by 
Watts in 1881, and a second by Veit in 1882. 

A short account of each will be g^ven. 

Case 2. — ^Watts's patient had a vaginal cyst which 
bulged from the anterior vaginal wall in the position 
of a urethrocele. The urethra was, however, quite normal. 

He laid open the cyst per vaginanif and to his surprise 
was able to pass a probe several inches without the 
slightest resistance. The probe passed to the patient's 
left side, and its tip was easily felt at a point midway 
between the umbilicus and the left anterior superior iliac 
spine. Watts thought this probe had penetrated to the 
peritoneal cavity, but I think it pretty clear that, as in my 
case, it was really between the layers of the broad liga- 
ment, where there was almost certainly some distension of 
the duct not noticed at the time, as it doubtless speedily 
collapsed when the vaginal cyst was opened. 

Case 3. — ^Veit's case (1882) was that of a married 
multipara, aged 47, who had a large vaginal cyst, 
which made micturition difficult, owing to pressure upon 
the urethra. The cyst bulged out between the labia 
majora as large as a child's head. 



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ASSOCIATED PAROVAUIAN AND VAGINAL CYSTS. 157 

The uterus was pushed over to the left by a tense elastic 
swelling in the right broad ligament, which clearly commu* 
nicated freely with the vaginal cyst. 

The case was treated by incision of the vaginal cyst, 
draining both it and the broad ligament cyst, and by cat- 
ting out a large piece of the lining membrane of the vaginal 
cyst to prevent reclosure. Cholesterine crystals were 
found in the fluid. The epithelium was flattened in type. 

The finger could be passed into the broad ligament cyst, 
and the ovary could be felt on its posterior and outer sur* 
face. 

Such cases have to be distinguished from a case like 
the following, which has many symptoms in common, but is 
clearly of a different character, being one of double vagina 
and uterus, imperforate on one side. 

Cask 4. — Miss T. P — was a patient of my father, who 
kindly permitted me to see her, and whose notes are here 
reproduced. — ^Aged 17. Is constantly "unwell,** dis- 
charge being gi'umous and somewhat offensive. Suffers 
much from pruritus and pelvic discomfort. 

February, 1891. — On examination the hymen is present, 
but very dilated. The uterus is rather larger than normal. 
Between the uterus and the left side of the pelvis is a 
tumour, larger than the uterus, and mobile, somewhat 
behind the level of the broad ligament. 

April, 1891. — In spite of vaginal injections the discharge 
persists, and continues to be very offensive. On examina- 
tion, the odour from the vagina is very foul ; on the left 
side of the vagina, reaching halfway down, a swelling is 
felt like a vaginal cyst, but no aperture opening into 
vagina can be detected, though it seems certain that one 
is present. The uterus is apparently normal. 

June, 1891. — No change, except that an opening into 
the cyst is discovered anteriorly. 

Patient was taken into a Nursing Home, and the vaginal 
cyst opened along the side of vagina to the level of the 
external os uteri. As the parts were very vascular the 



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158 ASSOCIATED PABOYABIAN AND VAGINAL CT8T8. 

vaginal cyst was opened by passing an india-rubber tube 
along its canal, and bringing it out at the top of the vagina, 
tightening it, and allowing it to work its way through, 
imitating one of Allingham's methods for fistula in ano. 

Later on, the sound was passed upwards and backwards 
into the body felt to the left of the uterus, and the finger 
could also be passed along the opened up canal, and the 
circle of the dilated neck of the distended half of the 
double uterus could be felt. The case, therefore, was 
clearly one of uterus bicomis septus with double vagina, 
the left half of the vagina being closed near the vulva. 
A drainage-tube was passed into the uterus (left half), 
and kept in for some weeks. 

This diagnosis was confirmed in August, 1891, when the 
vaginal canal leading to the left external os uteri was 
found to admit the tip of the finger for over an inch. 
The finger could then detect a normal external os uteri, 
and in January, 1892, the sound showed that the left 
half of the uterus was two and a half inches long and 
retroverted, whilst the right half was the same length and 
anteverted. The patient is now quite well. 

Where Miiller's ducts have not combined by absorption 
of their intervening septum, as in this case, Preund has 
stated, and. Winckel agrees with him, that one duct may 
take a spiral course and become anterior to the patent 
vagina, formed out of the other Miiller's duct. This 
would make the diagnosis between a distended Miiller's 
duct and a similar sized distended Wolfiian or Gartner's 
duct more difficult. 

There are many points of interest in connection with a 
distended Gurtner's duct. Its position whilst between the 
layers of the broad ligament is well known. 

It is agreed that most parovarian cysts arise from dis- 
tension of one of the vertical tubules of the parovarium, 
and that cysts so formed are rarely present before the 
age of seventeen, when the changes of puberty set up some 
activity in the vestigial remains of the Wolffian body. 

The three cases described above seem to prove that 



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ASSOCIATED PABOVABIAN AND VAGINAL CYSTS. 15^ 

sometimes the longitudinal tube of the parovarium run- 
ning at right angles to the vertical tubules may become 
distended into a cyst^ and Doran alludes to such a possi- 
bility. Usually the longitudinal tube thus distended would 
not be patent beyond the limits of the broad ligament^ 
and the resulting parovarian cyst would be indistinguish- 
able from a parovarian cyst due to distension of one of the 
vertical tubules. If, however, the longitudinal tubule, 
Gartner's duct, were patent along that part of its course 
which lies in the antero-lateral wall of the vagina, the 
condition would be precisely as was found in the three 
cases described above, viz. a parovarian cyst formed out 
of the broad ligament portion of Gartner's duct, with a 
channel leading from it, along the vaginal continuation of 
the duct, towards the base of the vestibule, forming a 
more or less continuous cyst along the vagina (see dia- 
gram, p. 161). 

The following case occurring in the practice of Mr. 
Milton, of Cairo, is not identical with the preceding three 
cases, inasmuch as, owing to patency of the duct at its 
vulvar termination, there was free discharge, preventing 
any distension of the duct along its course. It is also in- 
teresting firom other points of view, especially as regards the 
treatment adopted, which I do not think was very satisfac- 
tory, merely masking and not curing the abnormality. 

Case 5. — ^The case was that of an Egyptian fellah woman, 
aged 30, who from her earliest recollection had been 
subject to a watery vaginal discharge. At the age of 
thirteen she married, became pregnant, and was delivered 
of a healthy child, the discharge continuing during the 
whole pregnancy. On vapnal examination a very minute 
orifice, admitting only a catgut guide, was found on the 
vesico-vaginal septum, a little to the right of the middle 
line, and half an inch posteriorly to the vesical extremity 
of the urethra. Prom this issued, drop by drop, a pel- 
lucid fluid, to the amount of about two ounces per diem, 
having a specific gravity of 1026, and containing much 



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160 ASSOCIATED PABOYARIAK AND VAGINAL CYSTS. 

albumen, with some chloride of sodium. Urea and urates 
were absent. A fine urethral bougie, introduced with 
great difficulty, passed directly backwards along tho 
vesico-yaginal septum, and then, following to all appear^ 
ance the line of the ureter, penetrated to the whole of its 
length in the direction of the right kidney. The patient 
was most anxious to have something done to stop the con^ 
stant discharge. 

Mr. Milton decided not to attempt to close or destroy 
the canal, but to divert its opening into the bladder, so that 
its contents might flow away unnoticed with the urine. This 
was easily effected by separating a tongue of tissue com-r 
posed of the whole thickness of the vesico-vaginal septum, 
and containing the orifice and first inch of the duct, tuck« 
ing it up into the bladder, and closing the vesico-vaginal 
septum beneath it. Twenty-four hours after this operation 
was performed, the patient complained of severe pain in the 
right lumbar region ; this pain lasted for a few days, and 
required morphia for its relief. It was very probably due 
to retention of the contents of the canal from a kink at the 
point where it had been turned up into the bladder. The 
patient recovered completely, and left the hospital free 
from any vaginal discharge, but with an albuminuria, which 
in the future may, he says, greatly trouble some learned 
physician. 

The question of the course and termination of Grartner's 
duct after it leaves the broad ligament has not yet been 
definitely settled. Many observers have traced it along 
the broad ligament from its closed extremity, usually called 
Kobelt's tubes, above the ovary and the vertical tubules, 
downwards and inwards into the cervix, or into the vagina 
at the sides of, or anterior to, the cervix, but its course 
after that position has been reached is disputed. 

Max Schiiller, Fischel, Dohrn, Rieder, Skene, and others 
believe that it never persists as far forward as the urethra. 

The opposite view is taken by many. Thus Kocks of 
Bonn (and Garrigues acquiesces with him) declared that in 
80 per cent, of adult females the remains of Gartner's 



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ASSOCIATED PABOYABIAN AND VAGINAL CYSTS, 16} 



FT. 



Xa 



VT. Uterus. ▲• Aniu. 

B. Bladder. BX. Broad ligament. 

IT*. Ureter. o. Ovary. 

v*. Urethra. oj:*. Ovarian ligament. 

8J>. Skene's dncts. B.L. Bound ligament. 

T. Vagina. v.T. Fallopian tabe. 

e.o. Gartner's canals. h.m. Hydatid of Morgagni. 

xji.e. Max Schfiller's glands. P. Vertical tubes of parorarium. 

X. Eobeltf s tubules. 

(Modified from Skene.) 



VOL, XZZVI. 11 



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162 ASSOCIATED PABOYABIAN AND VAGINAL CY8T8« 

duct could be found as two small tubules opening just 
posterior to the meatus urinarius. 

The sow is specially stated to have persistent Grartner's 
ducts^ and DoHm states that in fcetal kittens they are 
always persistent along the vagina. 

Cases of vaginal cysts along tHe presumed course of a 
persistent Grartner's duct are very numerous, and are not 
alluded to here. 

Many observers have examined the lining membrane of 
these vaginal cysts, and the epithelium is variously de« 
scribed as pavement and cylindrical, whilst Johnston 
figures columnar and pavement cells in different sections of 
the same cyst. This diversity of epithelial lining is explained 
by Butherfoord in his exhaustive paper on '' Vaginal 
Cysts/' read at this Society in 1891, as being due to pres- 
sure of the contents flattening the original cylindrical 
form, so as to resemble the endothelium, such as is found 
in a lymph channel. Chalot, writing in 1892, believes that 
all cysts in the antero-lateral wall of the vagina, extendiiig 
upwards to the base of the broad ligament, if lined with 
cylindrical epithelium, are invariably WoMan. 

A very valuable work on '' The Duct of Grartner,*' by 
Bland Sutton, was published in 1886, giving his results of 
examination of seventy cows ; and Mr. Alban Doran, in his 
review of this work, points out thut as Grartner's ducts are 
generally admitted to be the homologues of the vasa 
deferentia, and as the vesiculsa seminales are diverticula 
of the vasa, close to their termination on the floor of the 
prostatic urethra, it follows that the Max Schiiller's glands 
of the female urethra are the homologues of the vesiculaa 
seminales, and he agrees with Bland Sutton in thinking 
that in woman, as in Bos, Skene's tubes represent the 
anterior termination of Grartner's ducts. This latter con- 
clusion is not, I think, correct. 

When this view was expressed in 1886, no cases had 
been published of a persistent Grartner's duct opening at 
the base of the vestibule ; but the cases now g^ven, and 
other cases of cysts formed out of the vaginal portion of 



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ASSOCIATED PABOYABIAN AND VAGINAL CYSTS. 163 

Grartner's ducts, show that the opening of Skene's ducts 
and the opening of Gartner's ducts are not necessarily 
identical in situation. 

In my own and Mr. Milton's cases the duct leading 
from the broad ligament was traceable along the whole 
length of the vagina, from the base of the broad ligament 
near the cervix forwards and inwards to a point at the 
base of the vestibule immediately below, and in both cases 
slightly to the right side of the urethral orifice, just as 
Kocks believes to obtain in 80 per cent, of adult females, 
and not, as Doran and others have described, opening just 
inside the urethral orifice in the position of Skene's ducts. 
Almost all observers who have been able to trace persis- 
tent Gartner's ducts as far forwards as the urethra, 
describe the opening as being just behind and to one side 
of the urethral orifice. The actual opening may vary 
much in different cases, and may in a few cases really 
open into Skene's tubes, and be a source of an obscure 
albuminuria. Freund, in describing one case of patency of 
the vaginal part of the duct, places the opening on the 
urethral ridge, three-tenths of an inch behind the urethral 
orifice. 

Bealdus Columbus, writing in 1559, gives an interesting 
account of a case observed by him. The following is a 
translation — (for original Latin see foot-note*) : 

* Bealdus Columbus, ' De AnatomicA,' p. 268 :—" Plroposito enim mihi 
Androgyno, sen bermaphrodito, snbiecto in quam eodem mare, et foemina, 
snperioribns et enim annis foeminam mihi videre , c(mtigiti quae praeter 
▼nluam, membro quoqne virili praedita erat, quod tamen non erat admodum 
crassum. Quftobrem in eius anatome generationis vasa accurate admodum 
per uestigaui, vasa seminaria, testesq' ; considerans, nunquid vlla inter baec 
communio, et consensus adesset: Tandem boc oomperi, vasa quidem 
praeparantia, ab aliarum foeminamm praeparantibus vasis non diiferre; sed 
deferentia differre: nam bipartita erant, et ezbinis quatema natura gennerat, 
ex quibus duo, quae etiam maiora erant, ad matrieis concanum destinabantur, 
reliqua duo ad penis radicem, qui glandularum parastatum expers erat. Hoc 
tam admirabile aiin» et speculatn erat qukm quod maiime: quo pacto 
natura prudens, sagaxq' ; locum satis tutum selegerat» per quod uasa baec ad 
penem deferri posaent: et quern admodum meatum» qui in ipso eat pene, 
perforarent : qui meatus in alijs tnm semini, tam lotio oSmnnis existit, bic 



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164 ASSOCIATED PABOVABIAK AND VAGINAL CYSTS. 

" The case of an androgynus or Hermaplirodite^ in whose 
one person the male and female alike are combined^ 
having been brought to my notice, I may mention that it 
fell to my lot formerly to see a woman, who in addition to 
a vnlva was endowed with a male organ as well, — ^not, 
however, a very thick one. Accordingly in the anatomy 
of this person I investigated the vessels of generation very 
accurately, the seed-vessels (ovarian blood-vessels) and the 
testes (ovaries) marking whether there was any commnni- 
cation and agreement between them. 

The result of my observations was that the spermatic 
(ovarian) arteries and veins did not differ from that of 
ordinary women, but the ovarian ligaments did ; for they 
were bipartite, and from the pair nature had developed 

Tero nrinae nihil quicqnllm opii aiferebat ; nam inrtar aliamm mnlierum mina 
exibat. vtenis antem, nee non vteri cemix k caeterarom foeminarum matrioe, 
coUoq'; nihil dittabat: sed in testibos discrimen erat; ni testei in hac 
crastiores erant, qdUn in reliqnis mnlieribos: seq qooad sitnm ipaonim 
nnUom diterimen depxaehendi. Pen! Bcrotum eontignum non erat, imo rero 
seroto pronufl carebat: ei dnobns mnaculit praeditoa erat hoios foeminae 
penis* non qnatnor, vt in maribns perf ectit. Praeterea penis huios herma* 
phroditi tenni pelle integebatar, nullum aderat praeputiii, sed duo spongiosa 
corpora* per quae duae arteriae ferebantnr, ab illis ortae, quae ad vesicS 
tendebant." 

N.B. — ^The abore translation is beliered to be correct. I have had the 
advantage of the opinion of Mr. J. W. Hulke» F.R.C.S., whose note may here 
be quoted, with reference to the old anatomical terms used. 

^The voM prseparaniia are the 'vasa semen preparantia,' and are the 
gpermatie veint. Cf. Bartholinus, 'Anat. Beformata,' p. 182, fig. ezplic. 
Tab. zxii; also Gibson, Thos., 'Anat of Man's Body Epitomized,' 1688, 
p. 167 ; ' Of the Genitals in Women,' chap, xziv ; < Of the Vasa Prsdparantia.^ 
Here plainly the ovar. arteries and veins are intended. Riolanus says of these 
that in females ' et vena et arteria bipartitss flnduntur.' 

"The 'vasa deferentia' are not the Fallopian tubes, but the ovarian 
h^ameni, which was regarded by old anatomists as a vessel, and is their 
* vas evacuatorium,' by which the female semen was conveyed from the ovary 
into the womb. The Fallopian tube was, by some, regarded as a spiracle, by 
which the fostus in uUro drew air for its breathing from the mother ; by 
others it was considered to be a vent through which the fuliginous vapours 
forming in the womb escaped from it into the belly. Fallopus called it 
' Tuba,' but does not seem to have rightly appreciated its true function, tho 
human ovum being to him unknown." 



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ASSOCIATED PAROVABIAN AND VAGINAL CTSTS* 165 

two pairs^ two of wluch^ and these tHe larger^ were attached 
to the hollow of the womb, the other two to the root of 
the penis, which was without a prostate gland. This 
(arrangement) was to the last degree admirable to look at 
and contemplate, showing how far-sighted and wise nature 
had chosen a sufficiently safe place by means of which 
these vessels might reach the penis, and pass through the 
orifice which exists in the penis itself. This orifice in 
other individuals serves alike for the semen and the urine ; 
in this case, however, it is of no help to the urine, for this 
last finds its way out as in other women. The uterus, 
moreover, and the neck of the uterus as well, do not differ 
from the uterus and the cervix of other women ; but as 
regards the testes there was a difference, for the testes 
(ovaries) in this case were thicker than in other women, 
but as regards the position of the latter I detected no 
difference. The scrotum was not attached to the penis,— in 
fact, the scrotum was altogether absent, and the penis of 
this female was endowed with two, not four muscles, as in 
the case of well-developed males. Moreover the penis 
of this hermaphrodite was covered with a thin skin ; no 
prepuce was attached, but two sponge-like bodies, through 
which two arteries made their way, sprung from those 
bodies, which extended to the bladder.^' 

It is difficult to credit the vague statement that these 
canals " ended at the root of the clitoris,'^ for if homology 
is of any value, it would tend to prove that if the Wolffian 
duct ended in the female urethra at all, it would do so in 
the part corresponding with the first part of the prostatic 
portion, which in this case is in the usual position of the 
female urethra. No microscopical examination was 
possible in 1559, but the genital glands were in the usual 
position of ovaries, and there is no reason to think they 
were testes. The woman, therefore, was almost certainly 
not hermaphrodite, and we may assume the canals to have 
been persistent Grartner's canals. 

It is recognised that vaginal cysts near the cervix may 
be due to a distended Gartner's duct, and if it be allowed 



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166 ASSOCIATED PAROVARIAN AND VAGINAL CYSTS. 

that Gartner's duct is sometimes present up to the base of 
the vestibule it will simplify the astiology of many cysts in 
the anterior parts of the vagina. Chalot^ the most recent 
writer on vaginal cysts^ is convinced that Skene's ducts are 
quite distinct from Grartner's ducts^ and gives one case in 
which he proved them to be so. 

It is probable that the formation of the vaginal cysts in 
some of the above cases was secondary to the distension of 
the broad ligament portion of the duct^ and that the 
vaginal portion of the duct was gradually opened up by 
the pressure of the fluid contents of the broad ligament 
portion^ under the influence of coughing and other intra- 
abdominal pressure. 

Patent Gartner's ducts may be more frequent than is 
imagined^ and may account for some of those cases of 
watery vaginal discharge the origin of which is obscure ; 
for in all the cases which were discharging^ the hole was so 
minute that it could only be detected when fluid was 
actually exuding through it. 

In this connection a case related by Mr. Lawson Tait is 
interesting. 

Case 6. — A, patient aged 60 consulted him for profuse, 
recurring, clear watery discharge from the vagina for the 
last thirty years, the cause having been variously diagnosed 
as hydrorrhoea uteri, polyuria, Ac. He discovered that the 
fluid came neither from the uterus nor bladder, but from two 
small apertures, one on each side of the urethra. Tem- 
porary closure of the canals by Pacquelin's cautery caused 
much pelvic distension, which was relieved when the 
accumulation of fluid reopened the closed orifices. 

Mr. Tait appears to have held to Morrison Watson's 
theory that these ducts, which he assumed to be Gurtner's 
canals, led into the peritoneal cavity, and nothing further 
was done, the discharge continuing till the patient was 
seventy years of age. 

If this was a case of patency of both Gartner's ducts 
from their commencement near the ovary to their ending 



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ASSOCIATSD FAROYA£IAN AND YAGIKAL CYSTS. 167 

near the nretlira^ a closure anywhere along the vaginal 
portion of the duct would have led to distension of the 
broad ligament portion^ and a parovarian cyst would have 
resulted. 

The question of treatment may also be alluded to. 

If suppuration has occurred^ there is probably no doubt 
that the best plan is to treat the combined cysts as an abscess^ 
by laying open the vaginal part of the duct by means 
of Pacquelin^s cautery knife so far back as the broad liga-. 
ment cyst^ which can then be easily drained and irrigated^ 
and will gradually contract down^ and^ finally^ completely 
close up. Even where suppuration has not occurred (as 
in Dr. MUton^s or in Mr. Tait's case) the same course 
might be adopted ; the broad ligament parovarian cyst^ if 
present^ being washed out with iodine solution^ and allowed 
slowly to contract. 

Mr. Milton's method of diverting the course of the duct 
into the bladder seems to have no advantages ; and if 
there is a vaginal openings one doubts if an abdominal 
section as proposed by Mr. Lawson Tait is necessary^ or 
even advisable, for if the parovarian cyst had to be enu- 
cleated from its broad ligament investment it might be 
difficult to effectually close the opening into the vaginal 
cysts, and unless the vagina were kept aseptic the patient 
would run great risk of septic abdominal infection occur- 
ring. 

The . conclusions which may be drawn from these cases 
seem to be as follows : 

1st. That (Partner's duct can be traced in some cases in 
the adult female from the parovarian to the vestibulum 
vulvae, ending just beneath and slightly to one side of the 
urethral orifice. 

2nd. Homology tends to show that Max Schiiller's glands 
are diverticula of Gartner's ducts, just as the vesiculsd 
seminales are diverticula of the vasa deferentia. Some 
evidence is given that Skene's ducts are not necessarily 
identical with the anterior termination of Grartner's ducts 
(as most of those who have traced Gartner's duct to the 



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168 ASSOCIATED FABOYABIAN AND VAGINAL CTSTS. 

vestibnle have tlionght)^ but that Skene's ducts lead 
directly and solely from Max Scholler's urethral glands^ 
Chi.rtner's ducts being continued to the vestibule^ behind^ 
but parallel to Skene's ducts. 

3rd. That Gkurtner's duct^ if patent^ may become dis- 
tended at any part of its course^ constituting a variety of 
parovarian cyst if the distension be in the broad ligament 
portion^ and a vaginal cyst if the distension be in the 
vaginal portion. The cases described are instances of the 
association of both of these cysts^ owing to simultaneous 
patency and distension of both portions of the duct. 

4th. Attention is drawn to these cases as affording ex- 
planations of some obscure cases of profuse watery dis- 
charge from the vagina^ not coming from the uterus or 
bladder. 

5th. The question of treatment is also approached^ and 
the opinion is expressed that where the whole duct is dis- 
tended the vaginal part of the cyst may be laid open as 
far as the base of the broad ligament^ and the broad liga- 
ment portion encouraged to contract and close up. 



Table of HomologoiAa Parts* 



Female* 
Ovary. 
FlRTovariiiiii* 
Gartner's canaL 
Duct from Gartner's canal to 

Max Schfiller's gland. 
Has Schflller's gland. 
Skene's ducts. 
Urethra. 

Urethral orifice and vestibale. 

Clitoris. 



Male. 
Testis. 
Epididymii. 
Vas deferens. 
Junction of vas deferens with 

vesicnla seminalis. 
Vesicnla seminalis. 
Ejaeolatory dncts. 
Upper part of prostatic portion 

of urethra. 
Lower part of prostatic and 

membranous portion of urethra. 
Glaus penis and spongy portion 

of urethra. 



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ASSOCIATED PABOVABIAN AND VAGINAL CT8TS« 169 

LiteratiLre^ 

1. Ballantyne and Williama. Structure of the Meso- 
salpinx. 

2. Chaleot (V.). ' Annales de Gynecologie/ July, 1892. 

3. Columbus (Realdus). ' De Anatomicft/ 1559, p. 268. 

4. Doran, ' Lond. Med. Rec.,' 1882, vol. x, p. 81 ; voU 
xiv, p. 248. 

5. Doran. Tumours of Ovary, Fallopian Tube, and 
Broad Ligament. 

6. Garrigues. Amer. Syst. of Gynaecology and Obstet« 
Gynaecol., vol. i, p. 68. 

7. Johnston.' ' Amer. Joum. of Obstet.,^ 1887, vol. xx, 
Nos. 11 and 12. 

8. Kock (Professor). ' Archiv fiir Gynaokologie,^ 1882, 
vol. XX, p. 487. 

9. Milton. ' Lancet,' October Uth, 1893, p. 924. 

10. Bieder. ' Lond. Med. Rec.,' 1885, p. 88. 

11. Bouth {AmBLTid). " Urethral Diverticula." Obst. 
Soc. Trans., 1890, vol. xxxii. 

12. Rutherfoord. " Cysts of the Vagina.*' Obst. Soc. 
Trans., vol. xxxiii, 1891, p. 854. 

18. Santoni, Des Kystes du Vagin, These de Turin, 
1890. 

14 Schuller (Max). Ein Beitrag zur Anatomie der 
weiblichen Hamrohre, 1888. 

15. 8hme. ' Dis. of Women,' 1889, p. 614. 

16. Sutton (Bland)* 'Joum. of Anat. and Phys.,* vol, 
XX, April, 1886. 

17. Tait (L.). Diseases of Women, 1889, vol. i, p. 102. 

18. VeiVs case. Handbuch der sp. Path. u. Therapeut., 
1877. ' Zeitschr. f. Geburtsh. u. Gynak.,' Stuttgart, 1882, 
vol. viii, p. 471. 

19. UTateon (Morrison). 'Joum. of Anat. and Phys.,* 
vol. xiv. 

20. WatU. ' Amer. Joum. of Obst.,^ 1881, vol. xiv, 
p. 848. 

21. WinckeU Dis. of Women, 1887, p. 146. 



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170 JLSBOCIATED PABOVAEIAN AND VAGINAL CYSTS. 

Tbe Pbbsidbnt expressed the thanks of the Societjr to 
Dr. Eouth for his able and instructive pa^r, which contained 
both exact and careful original observations, and laborious 
research into the preceding work of others upon the difficult 
subject discussed. 

. Mr. Alban Doran thought that the association of parovarian 
cvsts with cysts in the lower part of the genito-unnary tract in 
the same subject was strong evidence of their common origin. The 
rarity of cjsts in the lower part was the chief argument against 
the theory that the duct ever extended so low downwards, but 
such an argument was in no sense a proof. Tbe development 
and embryology of the female organs should be studied in a 
scientific spirit, and the observer must not look out for ducts 
which he wanted to find, else he was sure to find them, according 
to bis own opinion. Unfortunately, the next man who worked at 
the subject was apt to deny that any duct had been discovered. 
At present they must dwell on what bad actually been detected. 
Fischel (" Beitrage zur pathologischen Histologic der weiblichen 
Genitalien," • Archiv f . Gynak./ vol. xxiv, 1884, p. 119), in 
dissecting the uterus of a human foetus, found that Gartnei^s 
duct ran into tbe uterine wall and suddenly turned upwards in 
the tissues of the vaginal portion of the cervix, ending in a 
blind extremity, without reaching the vagina. However, this 
condition might be an individual anomaly ; nor did it follow 
that the blind extremity was the end of Gartner's duct, which 
might have extended further and become obliterated. Mr. 
button's theory concerning the homologies of Skene's tubes and 
Max Sohuller's glands was not unreasonable. The tubes were no 
doubt ducts of glands, yet they might also be the extremities of 
Gartner's ducts. Even if the ducts could be traced running 
outside the urethra and ending in blind extremities in the 
vestibule, that would not prove that Skene's tubes were not the 
true extremities of Gartner's ducts after all. The cutting off 
and dislocation of portions of festal structures was a common 
phenomenon in embryology. The clinical importance of Dr. 
Amand Bouth's communication was evident. Just as paro- 
varian cysts tended to burrow, sometimes inconveniently, 
between the layers of the broad ligament, 'so va^nal* cysts 
tended to burrow upwards, so as to lie in close association with 
the parametrium, peritoneum, and large blood-vessels.. On 
the other hand, cysts of Cowper's glands could not burrow in 
the same direction, owing to the disposition of the pelvic fascia. 
Hence, whilst tbe extirpation of large cysts of Cowper's glands 
was usually practicable and advisable, the dissecting out* of 
large v^inal cysts was dangerous and unjustifiable. 

Dr. Hbbbebt Spbncbb said that the paper was a highly 
important contribution to our knowledge of Gkui^ner's duct. 
One point he did not agree with, namely, the representation in 



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A8S0CIATBD PAROTABIAN AND YAGIKAL CT8TS. 171 

the diagram of the middle part of Gartner's duct as running in 
the fola of the broad liffament, whereas it had often ^n 
traced into the outer wall of the uterus, and he (Dr. Spencer) 
had a specimen of a f oatal uterus showing distension of the duct 
in that situation. He drew attention to the frequency With 
which a duct, more or less rudimentary, was to be found 
opening on either side of the urethra. He noticed that the 
cyst in Dr. Eouth's case had a smooth lining, a point worth 
noting in view of the frequency with which cysts arising from 
parovarial tubes deyeloped papilloma. While agreeing with 
what Mr. Bland Sutton had said as to changes in the epithelial 
lining of cysts, he (Dr. Spencer) thought that the racemose 
arrangement and many-layered lining of Skene's glands was so 
different from the single layer of Gartner's duct that it was 
evidence of a difference in origin. 

Dr. Olitsb did not consider vaginal cysts were so rare as 
was usually supposed. During the last twelve months be had 
had six cases, and out of this number he was of opinion that 
two had originated in Gartner's duct. Both had occurred in 
married women, and were located rather on the right side of the 
yaffina, although they inYolved very extensively the anterior 
wall of the vagina too. They extended from the vaginal roof 
to close upon the remains of the hymen. One cyst contained 
three ounces of fluid and the other six. In both cases the 
contents were similar to those foimd in parovarian cysts. The 
fluid was slightly opalescent; it was neutral in reaction, and 
contained albumen and chlorides. The sp. gr. of the fluid was 
in one case 1005, and in the other 1008. Dr. Oliver stated that 
the contents of vaginal cysts varied. Becently he had opened 
one on the posterior wall of the vagina in wmch the fluid was 
treacly, in consequence, no doubt, of the presence of blood, but 
he had long been disposed to believe that some vaginal cysts 
originated in Gartner's duct. 

Dr. Amakd Boxtth thanked the Society for their reception of 
the paper, and especially those members who had taken part in 
the interesting discussion. He was glad to find that such able 
comparative anatomists as Mr. Doran and Mr. Bland Sutton 
were, in the main, in affreement with him in regard to the 
conclusions at which he bad arrived. He thanked Mr. Doran 
for his remarks on the diagram exhibited, which clearly was not 
intended to be anatomically correct, as Dr. Grijfith suggested, 
but purely diagrammatical. It was impossible to draw several 
planes of tissue except in this way. In reply to Mr. Bland 
Sutton he said the duct laid open could not be a distended 
ureter, as it would not then have granulated up after incision. 
His specimen of vaginal cyst from a distendea Gkurtner^s duct 
in a cow was of great value, as showing unequivocally that such 
distension cysts do actually occur as suggesteo. The suggestions 



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172 ASSOCIATED PABOVABIAN AND YAGINAL CTSTS. 

in the paper were not jet capable of actual proof » for no anato^ 
mioal eTidence of a communication between (Partner's duct and 
Max Scbuller^s gland had been shown to exist* Homolo^, 
however, made this very probable. He did not agree with 
Mr. Bland Sutton's interpretation of Bealdus Columbus's case 
(1559), and belieyed that it was not a description of an her* 
maphrodite, but of a woman with persistent Gkurtner's ducts, 
all other organs being, so far as could be judged by the text, 
normal. He had in the diagram drawn the midme part of 
Gartner's duct as passing downwards outside the uterine 
muscle, as it appeared to him to obtain in his own case. He 
was aware, as stated bj Dr. Herbert Spencer, that Fischel and 
others described it as passing through the cervix to reach the 
vagiua, but others had held the view as drawn in the diagram, 
and the point was as jet undecided. Embrjologicallj there 
was no reason to suppose that the Wolffian duct was enveloped 
bj the Miillerian duct in the female except in a few cases, which 
might, he thought, be viewed as exceptional. He did not find 
the lining of the cjst anywhere papillomatous, its surface being 
unif ormlj smooth. The general idea of his diagram was founded 
on the basis of one Dublished bj Skene. He thanked Dr. 
Oliver for his remarks on vaginal cjsts, in the main con- 
firmatorj of his contention. 



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MAT 2nd, 1894. 
G. Ebnbst Heeican, M.B., President, in the Chair. 
Present— 44 Fellows and 2 visitors. 

The following resolution of the Council was put by the 
President from the Chair, and was carried unanimously : — 
"That the Obstetrical Society of London congratulates 
the Berlin Society for Midwivery and GynsDCology on its 
Jubilee, expresses its high appreciation of the scientific 
work of that Society in the past, and wishes for it con- 
tinued and increased activity and prosperity in the 
future.'* 

Books were presented by the President, Dr. Garrigues, 
and the Boyal Medical and Chirurgical Society. 

Thomas Henry Barnes, M.D.St.And. ; Frank A. 
Wagstaff, L.B.C.P.Lond. (Leighton Buzzard) ; and 
William Alfred Ward, L.B.C.P.Lond., were admitted 
Fellows of the Society. 

The following gentlemen were elected Fellows : — 
Eeginald Thomas H. Bodilly, L.R.C.P.Lond. (South 
Woodford; Andrew Bradford, M.D., C.M.Toronto (Lanark, 
Ontario) ; and Charles Ernest Gt>ddard, L.R.CP.Lond, 
(Wembley). 

The following gentleman was proposed for election :— 
Thomas Vincent Dickinson, M.D.Lond« 



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174 



A CASE OP EXOMPHALIO FCETUS. 
By Akthur E. Giles, M.D., and R. J. Peobyn- 

WlLLlAMS, M.D. 

This child was bom at the Greneral Lying-in Hospital, 
Lambeth, on the 17th of March, 1894. The mother, aged 
27, secundipara, believed the period of pregnancy to be 
seven months. The head midwife, Mrs. Messenger, attended 
the case in Dr. Williams' absence. She states that she 
was at first much puzzled to make out the presentation : 
it was a breech, but the mass of viscera could be felt, and 
she thought she had to do with a dead and decomposed 
foetus. The membranes had ruptured before admission. 
Labour proceeded without difficulty. The child made 
two or three gasps on being bom. The placenta was 
expelled immediately, the cord being very short. 

The child appears to be of the male sex, but the mal- 
formation of the genital organs renders this doubtful. It 
is thirteen inches long, and weighs three pounds. 

The heaid and upper extremities are apparently normal. 
The right foot is in a condition of marked talipes varus ; the 
left shows a slight talipes valgus. The anus is imperforate, 
and there is a spina bifida, the fiuid swelling being about the 
size of a pigeon's egg. The gap in the vertebrae can be felt. 

The trunk is contracted on the left side, causing the 
pelvis to tilt upwards on that side. The thorax appears 
normal externally. A mass the size of an orange, and 
containing viscera, projects from the abdomen. Its pedicle 
is six and a half inches in circumference at its base, 
and consists of skin for about half an inch all round 
except inferiorly. This skin is continued into the amnion, 
which forms a covering for the mass, leaving exposed, how- 
ever, on the under surface of the tumour, an area one and 



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BXOHPHALIC F(ETUB. 175 

a HaJf inclies in diameter. This area presents a corrugated 
appearance, and seems to have been in direct contact with 
the chorion. 

The cord, about seven inches in length, and straight, 
starts from the inferior margin of the exposed area, and 
coursing along its left side, reaches the front of the mass, 
to which it is closely bound down ; it then runs more 
freely to the placenta, receiving a partial investment from 
lihe amnion, which forms a membranous fringe on each 
side of it. 

Just below the visceral protrusion is a small fold, which 
appears to be the penis ; further down are two other folds 
of unequal size, which seem to be the separated halves of 
the scrotum. 

The specimen illustrates well the aetiology of this con- 
dition, which appears to be a form of arrested develop- 
ment. During the first few weeks of foetal life, as Ws 
has shown, the foetus iis anchored at its posterior extremity 
to the chorion by the allantois ; the amnion grows out 
from the cephalic end of the foetus, and extends back- 
wards over the dorsal surface. If the primitive attach- 
ment remain short, the amnion is unable to form a com- 
plete covei-ing for the foetus ; and the cord, instead of 
coming to lie freely with a complete investiture of amnion, 
runs along the uterine wall between the chorion and the 
amnion. The visceral surface of the abdomen of the 
foetus thus remains bound down to the side of the uterus, 
lying on the chorion ; the skin is unable to close over 
the viscera, and exomphalos results. A secondary effect 
is that the foetus necessarily assumes a position of dorsi- 
flexion, with lateral flexion superadded if the anchorage 
of the foetus is, as is generally the case, on one side of 
the middle line. Probably owing to the tension on the 
sides of the trunk, the spinal laminae are unable to unite, 
and spina bifida results. Similarly, owing to traction on 
the intestine, the hind gut is unable to reach the surface, 
and the anus remains imperforate. 

These points are all illustrated in this specimen, an4 



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176 EIDKEYS FROM A CASE OF ECLAMPSIA. 

from the attitude of the foetus its position in the uterus 
can be clearly deduced. 

For a clear exposition of the sBtiology of the condition 
we refer the reader to Dr. Dakin^s paper on " A Dissection 
of a Foetus the Subject of Retroflexion/' Ac, in vol. xxxii 
of this Society's Transactions (1890), p. 200. 

Dr. Amand Boxtth reminded Dr. Giles that he had shown a 
very similar specimen ('Transactions/ vol. xxxv, pn. 102 — 106). 
In common with the specimen now shown it had extroYerted 
abdominal viscera, spina bifida, torsion and flexion of spinal 
column, imperforate anus, talipes, and the characteristic skin 
tag to the right of the rudimentary genitals. He hoped the 
specimen would be dissected. 



KIDNEYS FROM A CASE OF ECLAMPSIA. 
By Lennabd Cutleb. 

Mrs. C. H — y aged 23, primipara, was admitted into the 
General Lying-in Hospital on March 13th, 1894, at 
10.45 a.m. Early in pregnancy she had severe vomiting 
conflning her to bed; she was otherwise well until March 
12th, when she complained of headache, and did not care for 
food. At 6.30 p.m. on that day she had a flt, becoming 
unconscious with twitchings of the hands and arms, biting 
the tongue and turning the head towards the left. This 
flt lasted two minutes. She had a second one at 8 p.m., 
and another at 3 a.m. on the 13th, when the convulsions 
became more frequent. 

On admission. — The patient was unconscious, rather 
ansBmic, with oedema of the face and legs. The pupils 
were dilated and insensitive. The head turned towards the 
right, and the mouth was flrmly closed. She was eight 
months pregnant. The urine was acid, straw colour, 
cloudy, solid with albumen, containing urea 1*2 per cent. 



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KIDNEYS FROM A CASE OF ECLAMPSU. 177 

and many granular casts. Chloroform was administered, 
and she was delivered by forceps ten minutes after admission. 

After delivery the pulse became very weak, and the 
patient rather cyanosed, with pin-point pupils. Ether was 
injected into the chest wall and the mouth forced open. 
The breathing soon became better, and the pulse improved, 
124; respirations 20. 

March 13th, 5 p.m. — After losing the effect of the 
chloroform the patient began to yawn frequently. The 
masseter muscles on each side acted alternately. The eyes 
were rolled and the head moved towards the right. The 
patient remained unconscious; said "Oh dear'' several 
times. She seemed thirsty, and drank half a pint of milk 
and some water. One minim of croton oil was given with 
results. Pulse improved, 120 ; resp. 26 ; temp. 97*2°. 

14th. — ^There has been no fit since delivery ; there is che- 
mosis in both eyes, but the swelling is going down in the legs 
and face. The patient is still drowsy and unconscious ; the 
pupils small. When asked if thirsty, she said "Yes." 
Takes liquid well, gj of whisky and gij of milk with gij 
of water every hour. 

Very little urine has been drawn off by catheter, and 
fomentations are being applied to the loins. The patient 
was more restless at night-time. Injectio Morphinse hypod. 
gr. i given at midnight. 

Urine acid, amber colour, cloudy, albumen two-thirds, 
1 per cent, urea, urates. Temp. 96*2°, pulse 106, resp. 18. 

15th. — Patient seems better this morning. Swelling of 
face and legs less, and chemosis has disappeared. Per- 
spiring all night. Has had no fit ; is still drowsy, but 
seems more conscious ; takes liquids well. Little urine is 
being excreted, but some was passed involuntarily on to a 
pad. An attempt to examine for retinitis was unsatis- 
factory, as the patient was so restless. Temp. 100*2° last 
night, this morning 98*6° ; pulse 120 ; resp. 26. 

Evening. — ^The bowels were not opened. Pulv. JalapsB 
Co. 5] was ordered every four hours until they acted ; 
1^ ounces of urine was drawn off, which was alkaline, 

YOli, XXXVI, 12 



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178 



KIDNIYB 9B0X A CASK OP SCLAKP8IA. 



cloudy^ one-fourth albumen^ and contained urea 1 per 
cent.^ no casts. 

16th. — Three drachms of jalap powder and a common 
enema had no result. One minim of croton oil was given. 
The patient was more drowsy in the morning ; could not be 



Date. 


Ubiub. 




Colour and reaction. 


8p. gr. depoiit. 


Albaneu. 


Urea. 


Mar. 18 
„ 14 
„ 15 
^ 16 


Straw; add 

Amber; acid 

CloQdy; 
alkaline 


Many granular 

carts 

Urates 

Phosphates 


Solid 
Two thirds 
One quarter 

w 


1*2 per cent. 
1 per cent 

»> 
'6 per cent 



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KtDKETS FROM A CASE OF ECLAHF8U. 179 

roused at all. Pupils reacted sluggishly to lights and were 
dilated. There was no oedema of the face^ slight of legs. 
Temperature last night 100*6°, this morning 99*2° ; respi- 
rations 20 ; pulse more tense, 120, regular. Moist sounds 
heard over lungs. No signs of consolidation. Patient is not 
sweating so profusely, but the skin is moist. The tongue 
is dry and coated. No twitching or sign of convulsion. 
There is now difficulty in getting the patient to take nourish- 
ment ; does not seem able to swallow. 12.15 p.m., Injectio 
Pilocarpin. hypoderm. gr. ^. Patient began to perspire 
freely five minutes afterwards. 5 p.m., seems better, takes 
notice when spoken to, and opens her eyes. Uttered some 
intelligible sounds. Pulse less tense, 120; resp. 20. Breath- 
ing quietly. Takes food more readily. Three ounces of 
urine were drawn ofiE this morning, none since ; alkaline, 
dirty straw colour, cloudy, one-fourth albumen, urea two- 
thirds per cent. 11 p.m., patient apparently sleeping 
naturally. Temp. 100*2°; resp. 20. Breathing quietly. 
Has taken plenty of fluid nourishment. A small quantity 
of urine has dribbled away on the pad. 

17th, 2 a.m. — ^The nurse reports that the patient 
suddenly began to breathe with difficulty, became ghastly 
pale, and died in less than ten minutes. 

Poat'inortem appearances. — Body well nourished, ansdmic. 
No cedema about the face, slight of the legs and lower 
part of back. About half a pint of fluid in peritoneal 
cavity. No oedema of glottis. Lungs : base of either 
lung congested and oedematous ; float readily in water ; 
much blood-stained mucus squeezes out. Heart : normal. 
About two ounces of serum in pericardial cavity. Spleen : 
congested and breaks down readily, not enlarged. Kidneys : 
right 7 ounces, left 6 ounces ; swollen, have somewhat 
rounded forms. Full of blood. Capsule strips readily. 
Surface smooth, mottled, and paler than normal. Cortex 
shows whitish patches, both under capsule and scattered 
through its substance, varying from size of a small pea to 
elongated narrow bands. These are clearly marked off 
from the rest of the cortical tissue, which is of a dark 



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180 KIDNEYS FBOH A CASB OF SCLAHPSIA. 

chocolate colour. What they are does not definitely 
appear under the microscope. Pyramids well marked, dark 
red. Bright red spots over the surface; small haemorrhages. 

Microscopically there is intense congestion with 
hsBmorrhage into the tubes, especially under the capsule. 

The lymphatics around the glomeruli and tubules are 
crowded with small cells, which for the most part are 
confined to their channels, but at one or two spots there 
are foci of small cells in connection generally with a vessel, 
which suggest small abscesses. 

The vessels show no marked thickening of any of their 
coats. Most of the glomeruli are intensely congested, some 
being so much so that the whole of their structure is 
obscured by red corpuscles. There is no thickening of 
Bowman's capsule or fibrosis of the tuft. 

Epithelium. — ^The lumen of many tubes is filled with a 
fibrinous substance. Most tubules, however, show what 
is apparently a running together of the cells, having no 
definite structure, and having their nuclei obscured ; the 
whole condition of the epithelium being similar to that 
often found in acute toxic conditions. The whole of the 
changes above described are almost wholly confined to the 
cortex, and are suggestive of a very recent acute inter- 
stitial nephritis with secondary affection of the epithelium. 

Liver normal, 3 lbs. 6 ounces. Intestines normal. 
Uterus contains a small amount of clot, measured 6 
inches from cervix to fundus. Brain : meninges healthy. 
Brain substance normal to naked eye. Ventricles normal. 
Microscopically healthy. 

I am much indebted to Dr. W. J. Penton for the 
preparation of the microscopical specimens. 

The Pbesidbnt said there were three points in Mr. Cutler's 
case worthy of attention. First, the condition of the kidneys. 
It had been suggested, and the view had found favour with the 
late Dr. Matthews Duncan, that in some cases at least of 
puerperal eclampsia the disease was not ordinary nephritis, but 
an acute atrophy of ^tbe kidney, pathologically allied to acute 
atrophy of the liver, and, like tnat disease, especially apt to 
attack pregnant women. Cases of such acute atrophy of the 
kidney nad been described by Hecker and by Angus Macdonald. 



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aAKGBENOUS UTEBINE FIBBOID. 181 

He (the President) had put on record a case in which the 
kidneys had been submitted to Dr. Charlwood Turner, a 
pathological expert unbiassed by any preconceived theories as to 
the nature of the disease causing eclampsia in pregnancy ; and 
Dr. Turner's report (* Trans.,' vol. xxxiii, p. 338) was that the 
kidneys showed '' changes attributable to some toxic matter in 
the blood." Mr. Cutler had read to them the report of a 
pathologist upon the kidneys now exhibited, and that report 
was that the changes produced were like those of blood- 
poisoning rather than of inflammation. These cases tended to 
show that the extremely acute disease which produced eclampsia 
in pregnancy was an acute change in the kidneys peculiar to 
pregnancy, and not ordinary nephritis. The second point was 
as to the temperature. Since the publication by Boumeville of 
acme cases ending fatally by rapidly rising temperature, it had 
been taught in text-books that the temperature was a valuable 
sign in prognosis ; that a rising temperature indicated danger, 
while if the temperature did not rise high, recovery was pro- 
bable. He (the President) was satisfied that death with a 
rapidly rising temperature was only one mode of death from 
puerperal eclampsia. He had published a fatal case (' Trans.,' 
▼ol. xxxii, p. 43) in which the temperature was subnormal 
throughout. In Mr. Cutler's case the temperature was never 
much raised. A very high temperature might indicate danger, 
but a low temperature did not show that prognosis was 
favourable. Third, as to the quantity of urine and urea. He 
(the President) had reported to the Society a number of cases 
of Bright's disease in pregnancy, and of eclampsia, which, taken 
together, showed that in the cases that got well, delivery or 
cessation of fits was followed by increased diuresis and augmen- 
tation of the quantity of urea excreted, while in those that did 
not recover there was no increase in the urea excretion after 
delivery or cessation of fits. He regarded this as the surest 
guide in prognosis. Mr. Cutler's case confirmed this view, for 
after delivery the quantity of urine and the percentage of urea 
contained in it steadily declined. 



GANGRENOUS UTERINE FIBROID REMOVED BY 
ABDOMINAL HYSTERECTOMY. 

By William Duncan, M.D. 

De. Duncan gave the notes of this case. The patient, 
aged 36, was admitted to the Middlesex Hospital on 
April 4th, 1894, very ill, and with a gangrenous mass pro- 



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182 GANOBBNOUS UTBBINK TIBBOID. 

trading from the vulva. She had been married ten years, 
had eight children (youngest three years old), no miscar- 
riages. 

She had always been regular every three weeks, her 
periods lasting only two days, until two years ago, when they 
began to appear every two weeks, and to last seven days. 

Since December, 1893 (five months), the loss had been 
almost continuous, and on March 31st it became very offen- 
sive. 

On examination the uterus was felt rising above the 
pelvic brim. Per vaginam the cervix was dilated and 
patulous ; projecting through the cervical canal and filling 
the vagina was a black stinking mass. The patient was 
very ill, with a temperature of 102*5° and pulse 142. 
Next day she was anaesthetised, and the sloughing mass 
removed with forceps. On introducing the finger into the 
uterine cavity a gangrenous fibroid, about the size of an 
orange, was found situated a little above the internal os 
uteri and to the right side. No distinct line of demarcation 
could be felt between the tumour and the uterine wall ; and 
as in one part there seemed to be very little tissue sepa- 
rating the finger in the uterus from the peritoneal cavity, 
it was decided not to attempt enucleation. The uterus 
was irrigated with a mercuric chloride solution, and an 
iodoform bougie passed into the cavity. 

On April 12th, as the patient seemed to be losing ground. 
Dr. Duncan decided to perform abdominal hysterectomy. 
An incision four inches long was made in the middle line 
of the abdomen, and the uterus with its appendages drawn 
out ; the broad ligaments were transfixed on either side, 
and the tubes and ovaries removed. Next a Koeberl6's 
serre-nceud was passed round the lower part of the cervix 
and tightened up ; then all round the clamp was packed 
with cotton wool soaked in mercuric chloride solution. 
The uterus was now cut across, when its cavity was opened 
a lot of horribly offensive matter escaped and soaked into 
the plugs. The parietal peritoneum was carefully united 
to the peritoneum all round the cervix just below the 



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OANOBENOUS UTEBINS FIBROID. 188 

serre-noeud^ and then the abdominal wound was closed and 
dressed in the ordinary way. 

The patient made an excellent and uninterrupted reco- 
very ; the clamp came away on the twelfth day, and now 
(May 2nd) there is only a small granulating wound left. 
The patient's temperature is normal, and she is gaining 
flesh and strength. 

Remarks, — Dr. Duncan said the case presented seyeral 
points of interest ; the first was as to the best method of 
treating a gangrenous fibroid. It was evident on exami- 
nation that any attempt to enucleate the tumour would 
lead to perforation of the uterus into the peritoneum, and 
certain death result. The choice lay between doing all 
that was possible in the way of irrigating the uterus 
with antiseptics whilst waiting for nature to throw off the 
sloughing mass, and removing the uterus. Dr. Duncan 
thought that, notwithstanding the grave condition the 
patient was in from septicaemia, removal of the uterus 
afforded her the best chance. 

Then came the question, should it be removed by the 
vagina or by the abdomen ? Removing it by the vagina 
had the advantage of complete removal, with perhaps a 
somewhat slighter risk. On the other hand, by performing 
abdominal hysterectomy the tubes, which were not un- 
likely to be diseased also, could be removed at the same 
time, and also there was some risk in tearing the diseased 
uterus whilst doing vaginal hysterectomy, and thus setting 
up fatal peritonitis. 

The specimen handed round showed that there was only 
an extremely thin layer of uterine tilssue between the 
tumour and the peritoneum, so that any attempt at enu- 
cleation must have caused perforation. The Fallopian 
tubes were apparently healthy, but the left ovary was 
dilated into a cyst the size of an unshelled walnut. 

Dr. Duncan said that the condition of gangrenous or 
phagedasnic fibroids was an extremely interesting one, and 
he was unaware that any good explanation of its cause had 
ever been put forward. 



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184 TWO CIBRHOTIC AND CYSTIC OVARIES. 

Dr. Peteb Hobbocks asked if microscopic examination had 
been made, because the cut surface of the tumour was flat like 
the section of a raw potato, which was characteristic of malig- 
nant growths, and not convex as occurred when a fibroid was 
cut across. Moreover he noticed the patient had had many 
children, which was against the view of fibroid. He could not 
obtain any milW juice on scraping the surface, but he should 
not be surprised if on histological examination it proved to be 
of a malignant character. 

Dr. Dakik asked why Dr. Duncan had preferred abdominal 
to vaginal hysterectomy, since by the latter method the ovaries 
and tubes, which Dr. Duncan thought it advisable to remove 
with the uterus in this case, could be quite completely extirpated. 
There would also have been no danger of infecting the perito- 
neum by the virulently septic secretion necessarily escaping from 
the uterine cavity opened in the abdominal operation, for the 
uterus could be removed per vaginam, without anv contamination 
of peritoneum by the cervix. In addition, although ventral 
hernia might not be very commonly observed after abdominal 
sections, there was little doubt that it was more frequent than 
was suspected by operators. It was certainly more frequent 
after hysterectomy than after most other abdominal sections. 
As far as Dr. Dakin's experience went there were no unpleasant 
results following successful rapid extirpation of the uterus. 

Dr. Duncan, in reply, said he had not yet examined the 
tumour microscopically, but sections were being prepared, and, 
when ready, would be shown to the Society. He preferred 
abdominal to vaginal hysterectomy in this case because he 
feared the uterus, being so thin, might tear during the latter 
operation, and thus its offensive contents get into the peritoneal 
cavity ; besides which, in many cases of vaginal hysterectomy, 
the tubes and ovaries could not be removed as completely as by 
the abdominal operation. He quite agreed with Dr. Dakin as 
to the occurrence of ventral hernia sometimes after supra- 
vaginal hysterectomy, but also intestinal obstruction had been 
known to occur from adhesion of bowel to the wound left after 
vaginal hysterectomy. 



TWO CIRRHOTIC AND CYSTIC OVARIES, WITH 
MICROSCOPICAL SECTION OF SAME. 

By Leonabd Remfby^ M.D. 



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185 



OVARIAN TUMOUR WITH GREATLY ENLARGED 
FALLOPIAN TUBE. 



By Pkteb Hobbooks^ M.D. 



DILATED FALLOPIAN TUBE AND OVARY. 

By T. 0. Hayib, M.D. 

A CoMM ITTEB^ consisting of Drs. Gow, Tate, and Hayes, 
was appointed to report on this specimen. 



Report of Committee on Mr. Ghrogono^s specimen of Foetus 
Aeephahis Acardiacus. Shown February 7th, 1894 
{p. 65). 

Wi, the undersigned, have met this day, and, after 
examining the specimen named above, have drawn up and 
signed the following report. 

The specimen is six inches long and four inches in its 
greatest width. 

It is divided by a marked constriction into two parts, 
an upper larger and a lower smaller. The upper part bears 
a misshapen right hand with three fingers, attached to a 
shoulder. There is no trace of a left upper extremity. The 
shoulder is firm ; almost all the rest of this portion feels soft 
and doughy. On its upper anterior aspect is a patch covered 
by black hair ; at the lower border of the hairy portion is 
a hemispherical protuberance, softer and pinker than the 
surrounding skin. Below this is a sac, on the surface of 
which the umbilical cord spreads out, and which is soft 
and thin-walled above, hard below. It contains viscera. 

VOL, XXXVI, 13 



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186 PCBTUS ACBPHALUB ACARDIACUS. 

The lower and smaller part of the foetus is firm, and 
bears two deformed feet, one of which has three toes and 
the other one. The toes, like the fingers, have nails. 
The feet are planted close together on the anterior aspect 
of this portion of the foetus. Neither in the cleft between 
the feet, nor anywhere else, can any trace of anus or of 
genital organs be found. 

Dissection. — In the visceral mass is a piece of intestine, 
terminating at one end blindly, and at the other in a mass 
of friable yellowish tissue. Two oval masses appear to be 
kidneys, but the specimen is too decomposed to allow of 
microscopic examination. Several vessels are also present, 
but nothing can be gathered from their distribution. 

The upper portion of the specimen consists mainly of 
four dilated and thin-walled cysts containing clear fluid ; 
they do not communicate with one another nor with sur- 
rounding structures. Each has a distinct cyst-wall. They 
are probably products of cedematous degenerative changes. 

Skeleton. — Occupying nearly the centre of the specimen 
is a piece of vertebral column, containing spinal cord. 
It terminates superiorly in a conical mass of bone, over 
which is situated the hemispherical protuberance above 
mentioned ; this, when cut into, is found to be a bursa 
(probably a pressure-bursa) . At the other end of the 
piece of vertebral column the spines are deficient for 
about an inch, the bodies of the vertebrad being alone 
present ; and beyond this portion again is a rudimentary 
sacrum. A hatchet-shaped piece of bone adjacent to the 
sacrum represents an iliac bone, articulated to which is a 
semi-cartilaginous mass representing the remainder of the 
pelvis. The femur is present on the right side, and to 
this is fastened the tibia, articulating below with a tarsus, 
of which the individual bones cannot be recognised. The 
foot terminates in three well-developed metatarsal bones, 
bearing the normal number of phalanges. On the left 
side the lower end of the femur is present, and the rest 
of the limb is like the right, except that the three meta- 
tarsal bones are fused, and there is only one complete set 



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SKBUTiL 8TBTBX 07 AOiFHALio AOABDiAO FOfiTUB (Dr. Orogono'f fpecimen). 
Diflteoted by Arthnr K. Gilei. 



A. Vertebral matf . 


L. Ischium and pnbes. 


B. Scapula, rigbt. 


X. Metacarpal bones. 


0. Spine of fcapnla. 


H. Phalanges. 


D. Bodies of dorsal vertebrsB. 


0. Left femar. 


B. Rigbt humerus. 


p. Right femur. 


v. Rigbt ribs, fused. 


Q. Left tibia. 


e. Bodies of lumbar vertebrsB. 


B. Right tibia. 


H. Iliac bone. 


8. Left tarsus and metatarsus. 


I. Radius and nlna. 


T. Right tarsus. 


J. Carpus. 


IT. Metatarsal bones. 


X. Sacrum. 


y. Phalanges, 




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188 fCETUS ACEPHALUS ACABDUCUS. 

of phalanges ; the others are indicated by several small 
nodules of cartilage. Four rudimentary and partly fused 
ribs articulate on the right side with the portion of spinal 
column that is complete. The right scapula is well 
developed, with spine^ acromion, and coracoid process. The 
clavicle is absent. The humerus, radius, and ulna are 
represented only by small cartilaginous nodules. The 
carpus is present, and supports three metacarpal bones 
with the normal number of phalanges. 

We learn that the mother of this monster was a strong 
healthy primipara, aged twenty-two years. Labour 
occurred at full term, and the monster was one of twins. 
The other was a fine healthy female child, and was bom 
naturally; the monster was bom next, and then the 
placenta was expelled. It did not seem to be abnormal, 
but had two cords, one normal, the other short and 
atrophied. 

The prepared skeleton and a drawing of the same are 
shown herewith. 

Walter Arthur Grogono. 

J. Bland Sutton. 

Arthur E. Giles. 



ON INTERMITTENT CONTRACTIONS OP UTERINE 
FIBROMATA AND IN PREGNANCY IN RELA- 
TION TO DIAGNOSIS. 

By J. Braxton Hicks, M.D., P.R.S., 

OONBULTING OBBTITBIO PHT8I0IAN TO OUT'B AND ST. MAST'S HOBPITALB. 

(Received January 27th, 1894.) 

This contribution, having already appeared in the 
' Medical Press and Circular ' of May 9th, 1894, p. 481, 
is not published here ("Laws,** .cl^ap- xvi, sect. 7). 
The discussion which followed the reading of the paper is 
published in the report of the May meeting of the Society 
in the ' Lancet,' vol. i, 1894, pp. 1191-2. 



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JCTNE 6th, 1894. 

G. Ernbst Hbsmait, M.B., President, in the Chair. 

Present — 47 Fellows and 2 visitors. 

Books were presented by Mrs. Tilt, Dr. Rocchi, and 
the American Association of Obstetricians and Gynecolo- 
gists. 

John Henry Chaldecott, L.R.C.P.Lond ; Henry W. 
Gibson, L.R.C.P.Lond.; Charles Ernest Goddard, 
L.R.C.P.Lond. (Wembly) ; Evan Jones, L.R.C.P.Lond. ; 
and William L. Livermore, L.R.C.P.Lond., were admitted 
Fellows of the Society. 

Andrew Bradford, M.D., C.M.Toronto (Lanark, 
Ontario) ; and William C. Loos, L.R.C.P.Lond. (Waltham 
Cross), were declared admitted. 

The following gentleman was elected a Fellow of the 
Society : — ^Thomas Vincent Dickinson, M.D.Lond. 

The following gentlemen were proposed for election : — 
Roland D. Brinton, B.A., M.D.Cantab. ; David Fair- 
weather, M.D.Edin. ; John Amallt Jones, L.R.C.P.Lond. 
(Aberavon) ; Albert William Denis Leahy, M.D.Durh., 
F.R.C.S.Eng. (Calcutta) ; ' -tineas John McDonAcll, 
M.B.Sydney (Queensland) , and David Petty, M.B.^ 
C.M.Edin. 

VOL. XXXVI. 14 



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190 FIBROMA OF THE OVAEY. 

The death of Dr. Tilt. 

The following resolution was put from the Chair and 
carried unanimously : — " The President, Council, and 
Fellows of the Obstetrical Society of London thank Mrs. 
Tilt for her valuable gift of books from her late husband's 
library, and take this opportunity of offering to Mrs. Tilt 
and family the expression of their deep sympathy in the 
great loss they and the profession have sustained in the 
recent lamented death of their highly distinguished Fellow, 
Dr. Tilt." 



FIBEOMA OF THE OVAET. 
By James Crawford, M.D. 

Dr. Crawford showed a specimen of a fibroma of the 
ovary from a woman who committed suicide by taking an 
overdose of opium at the age of forty-nine. It was stated 
that she married when she was eighteen years of age, 
had two children (girls) within three years, and that soon 
after the birth of the last child a very severe hasmor* 
rhage occurred, following an operation on the uterus the 
nature of which he was unable to ascertain ; from this she 
recovered after a long illness ; subsequently, however, and 
up to the time of her death, she had lived apart from her 
husband. 

At the post-mortem examination a tumour of the left 
ovary the size of an orange was removed, with its pedicle 
and some of the surrounding structures; the whole 
weighing about 6^ ounces. It was hard, smooth on the 
surface, irregularly globular in form, covered by peri- 
toneum, and on one side of the tumour was a small patch 
of mucoid degeneration. On making a section of the 
tumour it was solid throughout, while the ovary, from the 



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FIBBOHA OF THE OVASY. 191 

liiluin of which it apparently arose, was spread over the 
tumour from the attachment of the pedicle. The right 
ovary and the uterus he also noticed were normal in 
appearance, the latter bore no evidence of a severe opera- 
tion ; the cavity of the peritoneum was free from fluid ; 
the arteries (large branches) were atheromatous, especially 
at the base of the brain ; the walls of the left ventricle of 
the heart were hypertrophied, and the other organs were 
congested but otherwise apparently healthy. Mr. Tearsley, 
of the Westminster Hospital, kindly made a microscopic 
examination of the tumour, and reported it to be a pure 
fibroma. 

In the Westminster Hospital catalogue of specimens of 
morbid anatomy two specimens are described, and it is 
stated that fibromata of the ovary are rare. One of the 
tumours, a fibroma-myoma, weighed 13 pounds j the other, 
a small specimen, was a true fibroma. 

Mr. Doran, in an abstract published in the ^ Obstetrical 
Transactions,' vol. xxx, 1888, p. 411, says, "fibroma of 
the ovary is a well-known but rare disease. True fibrous 
tissue is naturally abundant in the tissue of the hilum 
(paroophoron) ; this fact is enough to account for fibroma 
of the ovary.'' He also states that muscular tissue is a 
constituent of the ovary, but confined to the blood-vessels, 
and free bundles derived from the ovarian ligament. 

Dr. Cullingworth ('Obstetrical Transactions,' vol. xxi, 
1879, p. 278), in describing a preparation of fibroma of 
both ovaries, mentioned that the tumours '^ replaced the 
structure of the ovaries, no portion of the normal tissue 
of the ovaries remaining," and (p. 288) referring to Dr. 
Goodhart's case* the tumour " was shown to spring from 
the outer layer of the ovarian stroma," again he says, 
Leopold has described a tumour in the structure of the 
right ovary. Mr. Bland Sutton, in his book on ' Tumours, 
Innocent and Malignant,' says '^ ovarian fibromata in a 
few rare instances have been demonstrated in the ovary. 
They may be regarded as ' pathological curiosities.' " 
• * Trans. Path. Soe. Lond.,' vol. xzv for 1874, p. 199. 



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192 

FIBROMA (?) OP THE OVARY. 
By Pbtbr Horrocks, M.D. 

The specimen was removed from a girl 22 years 
of age. At first the tumour lay in the pelvis, dis- 
placing the uterus upwards and forwards. One day it 
slipped up into the abdominal cavity, the uterus resuming 
its normal position. The tumour was removed by abdo- 
minal section, the patient making a good recovery. It 
was found to be a growth in the left ovary, somewhat 
ovoid in shape, and about twelve inches in its longest 
diameter and about ten inches round the widest part of it. 
Its surface was smooth and not very vascular-looking. In 
consistence it was very hard, and when cut across the 
surfaces did not bulge, but remained flat like a cut raw 
potato ; only a watery juice could be obtained on scraping. 
The sections under the microscope show that it is richly 
cellular, the cells having the characters of embryonic 
tissue. The intercellular stroma was distinctly white, wavy 
fibres in some places. From this and the fact that the 
patient was in good health, he considered it was a fibroma 
and not a sarcoma, and that it would not recur. 

Dr. HoRBOCKS, in reply, said that it was a very difficult matter 
to distinguish between embryonic tissue, inflammatory products, 
tubercle, sarcoma, and fibromata, and he might add myomata. 
He thought the specimen shown was a fibroma, but he would 
certainly keep the patient under observation and note any 
recurrence. 



LARGE SARCOMA (?) OF THE OVARY. 

By Peter Horrocks, M.D. 

The specimen was removed from a woman nearly 50 
years of age. She had been treated in the Soho Hospital 



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LABOB FIBROID TUMOUB OF THE UTERUS. 198 

twelve years ago for *' fibroid tumours of the womb ;*' this 
was her own statement. She came under the care of Dr. 
Bull, of Chislehurst, who was present at the operation, 
which was performed because the tumour was growing 
steadily larger, and the patient was in pain and was 
losing flesh. It was found to be a growth of the ovary, 
and the adhesions to the small intestines and the pelvis 
were very vascular and very formidable. 

The tumour was solid throughout, but softened in places. 
It measured thirty inches in circumference, and was more 
or less spherical. The cut surfaces remained flat, and 
yielded a not altogether clear juice. There had not been 
time to prepare good sections, and the one under the 
microscope, cut from a frozen piece of the growth, was not 
very satisfactory. 

Note, — The patient left the hospital three weeks after 
operation. 



LARGE FIBROID TUMOUR OP THE UTERUS. 

By Peter Horrocks, M.D. 

This specimen was shown in order to compare with the 
two preceding specimens. It was a uterine tumour, and 
it had been removed by abdominal section a few days 
previously. It grew apparently from the right cornu of 
the uterus, and the pedicle was about as thick as the wrist. 
A serre-noBud was put round it and the stump was drawn 
to the lower angle of the wound. The patient was pro- 
gressing favorably. The tumour is seen to be smoother 
on its surface than the other specimens, and on section 
the cut surfaces bulge so as to become convex, showing 
elasticity and contractility so characteristic of fibro- 
myomata. The scrapings were watery. 



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194 



UTERUS WITH PLACENTA PREVIA MARGI- 
NAXIS IN SITU. 

By G. F. Blacker, M.D. 

Db. BL^rKER showed a specimen of a uterus with a 
placenta prsevia marginalis m siiu. The specimen was 
obtained from the body of a woman who died in the 
eighth month of pregnancy from a cerebral tumour. 

The patient was aged 35 years, had had several mis- 
carriages and no living children ; unfortunately no his- 
tory could be obtained of the number of the miscarriages, 
nor as to the periods of gestation at which they occurred. 

The specimen consisted of the uterus, placenta, mem- 
branes, and cord. The uterus had been laid open 
anteriorly, and measured 9 inches vertically from internal 
OS to fundus. No difference in thickness between the upper 
and lower segments of the uterus was apparent on in- 
spection. On taking measurements, the fundus was found 
to measure i inch in thickness. The anterior wall three 
inches below the fundus -^ inch thick, six inches below 
the fundus J inch thick, nine inches below the fundus -^ 
inch thick ; the posterior wall one inch above the upper 
border of the placenta i inch, and with the placenta at the 
thickest part J inch. The cavity of the cervix, measuring 
1 i inches, was apparently quite distinctly marked off from 
that of the body, and was filled in the recent state with 
blood-stained mucus. The mucous membrane of the 
cervix presented the ridges of the arbor vitae well marked, 
and the mouths of 'numerous glands opening not only into 
the cervical canal, but also upon the vaginal aspect of the 
cervix. The placenta was attached to the posterior and 
left walls of the uterus, two thirds of it being to the left 
of the middle line. The lower margin reached accurately 
to the level of the internal os, but in the recent state 
no part of it actually overlapped the internal os. It 



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JBARLY TUBAL OVUM. 195 

measured 7 inches by 5J inches across at its widest part, 
and the cord, 16 inches in length, was inserted into the 
placenta li inches from the left margin, exactly midway 
between the upper and lower borders. The placenta was 
very easily separated from the lower segment of the uterus 
after death, and no difference could be detected in the 
ease with which the membranes stripped ofE the upper and 
the lower segment respectively. The right ovary was 
converted into a small cyst, the left contained a corpus 
luteum measuring i by f inch in diameter. The child, 
a female, lay in the second vertex position ; the cord passed 
from the placenta under and then round the child^s neck 
to the umbilicus. The patient had a slight discharge of 
blood from the vagina shortly before her death. 

The Pbbsident said the Societj was indebted to Dr. Blacker 
for exhibiting this instructive specimen, and for his detailed 
and exact description of it. He (the President) thought that 
the important point to investigate, in specimens of placenta 
prsBvia, was the condition of the decidua. The old mechanical 
theory of the production of placenta prsevia was unsatisfactory. 
Much had been published to show a connection between placenta 
prsBvia and disease of the endometrium; but we knew little 
definite about it. He hoped Dr. Blacker would examine the 
decidua in this case, and report upon it to the Society. 



ON AN EARLY TUBAL OVUM. 

By J. Bland Sutton. 

Our knowledge of the ovuline membranes in t 
of the tubal ovum is very defective ; this is due 
fact that nearly all the examples obtained by i 
operations are in the condition of moles. The sj 
which forms the subject of this communication is : 
It was obtained in the following circumstances. 



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196 BAELY TUBAL OVUM. 

Dr. Lords Beer asked me to see Madame M — , who^ he 
had reason to believe, was suffering from profuse internal 
haemorrhage due to rupture of a gravid tube. 

On seeing the patient there was no reason to question 
the diagnosis. She was thirty-five years old, mother of 
one child, and had not been pregnant or missed a period 
for fifteen years until April, 1894. Fourteen days after 
this period was due the patient complained of pain in the 
pelvis. April 27th, she was ill, and sought medical advice ; 
April 28th, she was confined to her bed ; April 29th, 
about four o'clock in the afternoon, she experienced 
severe pelvic pain and passed into a state of alarming 
collapse. At the time of my visit (a few hours after 
the onset of these alarming signs) the woman was 
blanched ; pulse scarcely perceptible at the wrist ; voice 
reduced to a faint whisper ; dulness in each iliac fossa ; 
recto-vaginal fossa distended ; movement of uterus caused 
pain ; cervix soft and slightly patulous. 

The diagnosis of primary intra-peritoneal rupture of a 
gravid tube was obvious enough. Abdominal section was 
carried out two hours later. A large quantity of blood 
escaped as the peritoneum was incised ; an ovum was 
detected still lying in the right Fallopian tube, which had 
burst. The tube, ovary, and adjacent portion of the 
mesosalpinx were removed after the usual method. A 
large quantity of blood and clot was removed by free irri- 
gation with warm water. The incision was sutured in the 
usual manner. 

The patient rallied fairly well, but she unfortunately died 
sixty hours later. 

The ovum is represented of natural size in Fig. 1 ; the 
embryo is lodged in an amnion as usual. The chorion is 
beset with villi, which are especially developed at one pole 
of the ovum, where they receive the allantoic vessels. A 
careful examination of the ovum also shows that a space 
exists between the allantois and chorion. To this space I 
wish for a few moments to ask attention. In the early 
ovum there is a relatively large space between the amnion 



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EARLY TUBAL OVUM. 197 

and the chorion ; this space, filled with albuminous fluid, 
has not, so far as I know, received a specific name from 



Fio. 1. — The tubal ovum from Madame M — , showing the space 
between chorion and amnion, and the polar disposition of the 
chorionic villi, (Nat. size.) 

embryologists. It will serve our purpose to-night at all 
events to speak of it as the subchorionic space (Fig. 2). 



Allantois. 
Umbilical vesicle. 

Amniotic cavity. 

Amnion. 

Sub-chorionic 
space. 

Chorion with villi. 



Fio. 2. --Diagram of an early ovum, to show the arrangement of 
the membranes. 

As the embryo increases in size the amnion encroaching on 
this space gradually obliterates it, but for many weeks a 
potential space exists between the amnion and chorion. 




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198 BAELY TUBAL OVUM. 

like that between pulmonaiy and visceral pleurae. TliiB 
space was clearly demonstrable in the ovum the subject 
of this communication. 

These facts throw some light on the constitution of the 
tubal mole. An examination of a typical mole (Fig. 3) 



Fio. 3.— A tubal mole. (Nat. size.) 

shows that the blood is limited by two membranes, of which 
the inner one is the amnion and the outer the chorion. 
It is therefore obvious that the blood occupies the sub- 
chorionic space. This at once explains the elliptical shape 
of many moles, for if the efEusion of blood happens at the 
time this space is large, the amnion will be squeezed to 
one pole of the ovum. 

A very important question arises out of this observation. 
Many are content to believe that a mole is formed by an 
irruption of maternal blood into the ovuline membranes. 
In the face of the observed facts mentioned above, this 
loose opinion must " go to the ground.'* The bhod is 
doubtless furnished by the ovuline vessels; it therefore 
follows as a corollary that tubal moles are produced by 
causes acting within the ovum. Again, in some cases a 
mole is found in situ but no blood is found extravasated 
into the lumen of the tube. In such specimens it is clear 
that the blood must come from some source within the 
ovum. 

The local development of the chorionic villi and their 
relation to many grave changes which occur in gravid 
tubes might with great advantage be discussed in con- 



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EARLY TUBAL OVUM. 199 

nection with this interesting ovum. I refrain, however, 
because I do not wish to obscure the chief point of my 
communication, which is briefly this : 

A tubal mole is formed by blood extrnvasated from the 
ovuline veaseh into the subch or ionic chamber, 

I venture to ofEer these observations to the Society as a 
contribution to those studies so exquisitely and eloquently 
indited by Sir William Priestley in his lectures on the 
'' Pathology of Intra-uterine l)eath." 

Dr. Petsb Hobbocks asked if Mr. Bland Sutton had exa- 
mined the blood microscopically, because if it were of foetal 
origin it ought to exhibit characters difEerent from these of the 
maternal blood. In an embryo so young the blood-cells were 
recently mesoblastic, and had distinguishing features. He had 
always taught that an ovum might perish from hsBmorrhage 
from the chorionic villi (foetal), or from maternal sinuses 
(maternal), or from both, and he thought most would agree to 
this. If the space which Mr. Sutton proposed to call "sub- 
chorionic" could be easily demonstrated in other specimens, it 
might be possible to discover the difference between death due 
to foetal or to maternal causes. At the same time he thought 
careful examination of the blood-clot should be made. 

The Fbssidskt said that the theory now propounded by Mr. 
Sutton was so novel and ingenious, and far-reaching in its con- 
sequences, that he rather regretted that it had not been put 
before the Society in the form of a paper, so that they might 
have had time to consider it before expressing any opinion 
about it. In all the so-called "carneous moles" formed in 
utero the clots were outside the amnion, and in many the amnion 
was incompletely in contact with the chorion. 

Note. — ^When this specimen was exhibited to the 
Society, it was suggested that if the blood in the sub- 
chorionic space is furnished from the embryonic circulation 
the corpuscles ought to exhibit certain peculiarities. Since 
the paper was read Mr. Bland Sutton has had one oppor- 
tunity of testing the point, and found that the red cnr- 
puHcles were nucleated and the white cells were especially 
numerous. 



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200 

UTERINE FIBROIDS. 
By J. D. Malcolm, M.B., CM. 

Mb. Malcolm showed two fibroid tumours removed by 
abdominal hysterectomy from a patient a week after she 
had miscarried in the sixth month of pregnancy. The 
operation was performed because from the third to the 
■sixth day after the miscarriage the temperature steadily 
rose to 103-8° P., the patient seemed to be rapidly going 
from bad to worse, there was no reasonable prospect of 
a change for the better, and the exact condition of the 
parts, as well as the nature of the tumour or tumours, was 
uncertain, while the vaginal discharge was odourless and 
apparently healthy. The uterus was found acutely retro- 
verted with a large fibroid in its anterior wall extending 
high into the abdomen, and a smaller one in its posterior 
wall firmly fixed, but not adherent, in Douglases pouch. 
On the larger growth being brought out of the abdomen, 
the posterior one was released, and could also be brought 
out. Both tumours and the greater part of the uterus were 
removed. Section of the posterior growth showed an 
ashen-grey colour, quite different from that of the other, 
and which seemed to indicate that sloughing was taking 
place. A chart was exhibited showing an immediate fall of 
temperature after the operation, and a satisfactory record 
of the febrile condition during the ten days that had elapsed. 

October 1st, 1894. — The patient made a complete re- 
covery. 

Dr. Amand Eouth stated that when recently removed from 
the abdomen, the retro-uterine fibroid, which had during the 
previous days been the main seat of pain, was undoubtedly 
undei^oing very rapid retrogressive changes, being soft and 
evidently fatty throughout its main bulk, but it also seemed to 
be on the point of sloughing in two or three places. As this 
was a rare condition, a microsopical examination would be very 
valuable. It was this rapid degeneration, and absorption of 



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UTBBINE FIBROIDS. 201 

effete products, which almost certainly caused the septic tempe- 
rature, which dropped almost to normal as soon as the tumour 
was removed. 

In reply to the President, Mr. Malcolm said that the broad 
ligaments were tightly stretched over the fundus uteri between 
the tumours, but by tying and dividing them they were allowed 
to retract, and the tumours could then be drawn forward, so that 
it was possible to place a wire round the base, including the tied 
broad ligament. 



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202 



LIGATURE AND DIVISION OF THE UPPER PART 
OF BOTH BROAD LIGAMENTS, AND THE 
RESULT AS COMPARED WITH THAT FOL- 
LOWING REMOVAL OF THE UTERINE AP- 
PENDAGES. 

By Leonard Rbmfrt, M.A., M.D., B.C.Cantab., 

ASSISTANT OBSTBTBIO PHYSICIAN, ST. OBOBOB'S HOSPITAL; OBSTBTBIC 
PHYSICIAN, GBBAT NOBTHBRN CBNTBAL HOSPITAL. 

(Received Jane 80th, 1894.) 
{Abstract.) 

A CASS of bleeding fibroid is cited, in which the above opera- 
tion was performed as an alternative to oophorectomy, the latter 
being impossible owing to the conditions present. 

The procedure is compared with that of oophorectomy : (1) 
anatomically, especially as regards the circulation ; (2) as to 
result. 

The principal theories concerning the amenorrhoea after 
removal of the appendages are mentioned and discussed. 
Changes in the circulation with lessening of blood-supply to 
the uterus are considered to form the chief factor in its causa- 
tion — a theory supported by the history of the case given. 

The blood-supply of the broad ligament is illustrated by an 
injection experiment. 

A FRW notes from a long case will serve not only to 
illustrate the effect produced by ligature and division of 
the upper segment of the broad ligaments^ but also to 
extend the inquiry as to why amenorrhoea is so generally 
produced by removal of the uterine appendages. The report 
of a single case is not of much value^ but inasmuch as 
this operation is not likely to be repeated, the effects pro- 
duced should be placed on record. 



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LIQATUBB AND DIVISION OF BOTH BROAD LIGAMENTS. 208 

The patient, A. C — , who was 47 years of age, 
had been treated as an out-patient at the Gfreat Northern 
Hospital during several months for metrorrhagia due to a 
large fibroid uterus, the whole mass being the size of 
a cocoa-nut. Various drugs, e. g. ergot, hamamelis, 
hydrastis, bromides, and sulphate of magnesia, as well 
as vegetable dieting, had been tried without success, and 
owing to the continual floodings the woman was becoming 
very weak. In August, 1891, she was admitted as an in- 
patient, and it was decided to remove the appendages. 
This, however, could not be done, as they were so densely 
adherent that separation was practically out of the question. 

Two ligatures were passed through the upper part of 
each broad ligament, one close to the uterus, the other 
about one inch away, including the tube and ovarian 
artery. The latter were then divided between the knots. 
The patient made a good recovery. No metrostaxis fol- 
lowed the operation. After two months there had been 
no haemorrhage, and the tumour was smaller. All went 
well till the end of the third month, when the metrorrhagia 
commenced again, and gradually become as profuse and 
frequent as ever. 

Six months after the operation, the bleeding being still 
copious, the uterus was removed per abdomen by the 
extra-peritoneal method, and the woman was soon quite 
well. 

Remarks, — My object is to draw a comparison between 
the- temporary amenorrhcea produced by the operation 
described, and the permanent amenorrhcea usually brought 
about by oophorectomy, hoping thereby to cast some light 
on the causation of the latter. As to why removal of the 
appendages so generallyputs a stop to menstruation, thereis 
still difference of opinion. There are four principal theories : 
(1) tubal ; (2) nervous ; (3) ovarian ; (4) circulatory. 

(1) Mr. Lawson Tait says, " In a pretty large pro- 
portion of cases (probably 30 per cent.) in which both 
ovaries are thoroughly removed, but where the uterus and 
tubes are untouched, menstruation goes on undisturbed." 



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204 LIGATURE AND DIVISION OF THV 

Again lie says^ " I have found by clinical experience that' 
removal of the tubes without touching the ovaries at all will 
arrest menstruation in about 95 per cent/' 

(2) Dr. Johnson^ in the ' American GynsDCological 
Journal^' 1888^ says that " a nerve-trunk which runs in the 
angle between the round ligament and the tube is a possible 
governing structure for menstruation^ and that section of 
this does exactly what section of the chorda tympani does 
to the submaxillary gland." With reference to this Mr. 
Tait says, " I always aim now for the destruction of this 
trunk, and since I have done so my exceptional failures 
have diminished beyond doubt.*' 

(3) The ovarian theory is refuted by the facts that the 
ovaries have several times been removed without cessation 
of menstruation, and also that cystic disease on both sides 
has not caused amenorrhoea. 

(4) Lastly, are the effects produced by oophorectomy duo 
to lessening of blood-supply ? — ^a result readily suggested 
by the usual suppression of menses after the operation. 

In oophorectomy a considerable segment of the ovarian 
artery, in its course through the broad ligament, is in 
ordinary cases removed, so that the uterus is deprived of 
the blood brought by it. No collateral circulation can 
take place, and the uterine artery has to do all the 
work of supplying the uterus up to the summit of the 
fundus. This amount of blood would be small and specially 
inadequate for the wants of a fibro-myoma, the supply 
not being sufficient for menorrhagia or metrorrhagia to 
occur. 

In the case cited in this paper, the ovarian artery was 
only tied and cut near the uterus, and so all its branches 
to the broad ligament and its structures were left intact, 
but the uterus itself was deprived of supply from it. 
Temporarily the same condition existed as after oophorec- 
tomy as far as the uterus was concerned, i, e. the supply 
to it by the ovarian main trunk was cut off. The many 
branches of the ovarian artery to the tubes and ovaries, and 
those running down and across the broad ligament to the 



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UPPER PART OF BOTH BBOAD LIGAMENTS. 

trnnk on the side of the uterus^ which is formed normally 
by the uterine and ovarian vessels and which acts really 
as a reservoir^ were in thid case left intact. 

Now, presumably in time all these branches would 
become dilated, and would probably eventually by helping 
the branches of the uterine cavity, and also by running 
directly to the lateral trunk on the uterus, bring in as 
much blood as originally. This perhiips happened here, 
and so the haemorrhage returned. That there is an anas- 
tomosis in the broad ligament between the uterine and 
ovarian branches I think is shown by an experiment I 
have made in the way of injection. The ovarian artery 
was injected with red size, and the uterine with blue. 
On holding the broad ligament before a light, red vessels 
were seen in the upper part and blue ones in the lower 
part, while in each case on nearing the centre the colour 
changed to a mauve, and the same gradation of tint was 
seen in the superficial vessels on the sides of the uterus 
after a thin section had been cut off. 

In oophorectomy, a considerable segment of the ovarian 
being removed, the collateral circulation cannot be estab- 
lished, and so the blood-supply to the uterus is practically 
only from the uterine artery. Hence it is that when a 
fibroid is present, it decreases in size after the operation ; 
in fact, the uterus itself has become smaller in cases where 
removal of appendages has been performed as a treatment 
for neurosis. The occasional failure of oophorectomy to 
prevent bleeding would be accounted for, I should suggest, 
by an incomplete removal, i.e. when only a very small 
segment of the ovarian artery is removed, or possibly 
where the artery is left intact. In conclusion, the case 
quoted, and the experiment on the circulation of the broad 
ligament, appear to support the circulatory theory. 

Dr. Petsb Hobbocks said the case, though short, opened up 
a wide subject. He had never himself seen a case where both 
ovaries had been completely removed and yet menstruation 
had continued for any length of time. Operators knew how 
difScult it was in many cases, particularly in fibroid tumours of 

VOL. XXXVI. 15 



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206 LIGATURE AKD DIVISION OF THE 

the uterus for which oophorectomj was done, to be quite sure of 
removing the ovaries entire. On the one hand if the ligature 
was placed close to the tumour, and the pedicle cut close to the 
ligature, there was grave risk of hemorrhage from slipping of 
the pedicle, and on the other hand if the l^ature was placed 
further from the tumour and the pedicle cut as near the ovary 
as possible so as to give a good distal portion, then a small bit 
of ovarian tissue was very apt to be left in this distal portion, and 
this was quite enough to keep up menstruation. He had never 
been able to find the nerve which was said to influence men- 
struation, and he should like to be convinced of its existence 
before accepting this view of its function. There could be no 
doubt about the influence of the nervous system upon men- 
struation. He quoted cases of amenorrhoea from shock. But 
he still believed that the ovaries were essential to the function 
of menstruation, and that whilst ovulation could take place 
without menstruation, menstruation could not take place without 
ovulation. 

Dr. William Duncan said that though the last speaker had 
seen no case in which the catamenia continued after removal of 
the ovaries, and that he believed when such an occurrence 
happened it was due to incomplete removal of those organs, 
he (Dr. Duncan) had four cases in which, many months after 
complete removal of the appendages, the patients suffered from 
menorrhagia, to account for which he was at a loss, except that 
the ligatures tying the stumps of the pedicles were perhaps 
causing irritation. Again, he had several cases in which the 
ovaries and tubes were so completely matted down in the pelvis 
that although he was able to tie the stumps beyond the ovaries, 
still he had thought it safer in cutting across the pedicle to leave 
a little of the firm ovarian tissue so as to prevent slipping of the 
ligature, and yet in none of these cases had there b^n any 
subsequent menstruation. He believed that as long as no 
ovarian tissue was left at the proximal side of the ligature, a 
little left on the distal side was of slight moment. 

The Pbbsident thanked Dr. Bemfrey on behalf of the Society 
for his report of an interesting case. Other cases had been 
published in which the broad ligaments had been tied, by Dr. 
Murphy in the Society's ' Transactions,' vol. xxvii, and by Dr. 
Kilner Clarke in the ' British Medical Journal,' 1893, and in 
these menstruation was not arrested. It had been proposed to 
tie the broad ligaments in order to arrest the growth of malig- 
nant disease. Dr. Eemf re/s case, with the others that he (the 
President) had referred to, had an important bearing on this 
proposition. 

Dr. Amand Boxjth pointed out that there was another 
explanation of hsemorrhl^^e persisting after the removal of the 
appendages for bleeding fibroids besides the occasional &.ct 



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UPPEB PART OF BOTH BBOAD LIGAMENTS, 207 

tliat the ovaries had been incompletely removed, viz. tliat a 
polypus might have been present, unsuspected, and would con- 
tinue to cause metrorrhagia. He had dilated the uterus in 
three cases of persistent hsBmorrhage after oophorectomy, finding 
a polypus in two, and a cluster of villous growth in the other. 
This showed the importance of exploring the uterine cavity 
wherever possible before removal of the appendages in cases of 
fibroids. He believed that although the ovaries greatly 
influenced the menstrual cycle, it was through the medium of 
nerves (ganglionic), passing between the ovary and uterus, and 
it must be remembered that in any operation for the removal of 
the ovaries, not only were the tubes and ovarian vessels also 
removed, but with them many nerve filaments, so that it was 
impossible altogether to ignore the nerves as the cause of men- 
struation. 

Dr. BsMFBY, in reply, thought the suggestion that the 
temporary amenorrhoea in the case was probably caused by shock 
could scarcely be supported, considering the comparative slight- 
ness of the operation, and the fact that menstruation did not 
return for three months. The interference with the circulation 
as shown in the paper readily accounted for it. He could 
not agree with Dr. Horrocks's opinion that removal of both 
ovaries ensured amenorrhoea, as many cases had been brought 
forward in which complete extirpation of those oi^ns had failed 
to bring on a menopause. The explanation given that in such 
cases complete removal of all ovarian tissue was not effected, 
and therefore that amenorrhcea did not follow, was naturally 
not easy to refute, and the basis on which it rested was con- 
sidered insufficient. As to the argument that shrinking of the 
ovaries at the menopause favoured this theory, Dr. Bemfry 
pointed out that the ovarian atrophy in late life was only part 
of a general atrophy, viz. of uterus, vagina, &c., a condition 
accompanied by diminished blood-supply, and therefore that it 
rather strengthened the circulatory theory advocated in the 
paper than otherwise. 



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208 



A CASE OF ADENOMA OF THE PORTIO VAGI- 
NALIS UTERI FORMING A DEPRESSED SORE 
OR ULCER. 

By Jambs Beaithwaitb, M.D.Lond., 

0B8TBTBI0 PHTSIOIAN AKD BTTBGEOK TO THB LBBPB GBNBRAL IKFIRMABT. 

The case which I venture to bring before this Society 
shows the great variability of the type, both pathologi- 
cally and clinically, which adenoma of the uterus is capable 
of assuming. 

I have myself never before met with adenoma of the 
uterus in any other form than as a growth, usually at 
first polypoid. In the later stages of the disease destruc- 
tion or breaking down occurs here and there in parts, 
just as in ordinary cancer, but never in the early stage of 
the disease, at least not in my experience, nor can I find 
any record of adenoma forming a nearly stationary de- 
pressed ulcer. 

S. W — y aged 54 years, was admitted into the Gynaeco- 
logical ward of the Leeds Infirmary in September, 1893. 
She was a worn-looking woman, tldn, and in poor general 
health. She had had three children at full term, and 
four abortions, the last being eighteen years ago. 

Menstruation ceased at forty-six, and she remained free 
from any discharge until two years ago, when she became 
subject to what she calls a " yellow-coloured discharge,*' 
not, however, much in quantity, but pretty constant. There 
was no pain. On examination a suspicious place was felt 
to the left side of the os, which on putting the patient in 
the lithotomy position could be brought within easy exa- 
mination by the eye. 

It then appeared to be a shallow ulcer, for it was a 



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ADENOMA OF THB POBTIO YAQINALIS UTERI. 209 

Uttle below the general level of the surface. The colour 
was a dull red, and strongly contrasted with the surround- 
ing paler mucous membrane. It was in diameter two 
thirds of an inch^ and nearly circular. It bled very much 
on even very gentle examination with the finger. I 
thought it was not cancer on account of its extreme soft- 
ness to touch. There was not the least crispness, and no 
apparent up-growth. It seemed quite superficial, and 
there was no trace of infiltration in the surrounding parts. 
The length of the history of the case also favoured the 
idea of its not being epithelioma, at the same time the 
age of the patient and the ready occurrence of haemor- 
rhage rendered the matter doubtful. I removed the 
growth with the scalpel and scissors, so as togo as I thought 
at the time beyond and beneath it, and afterwards curet- 
ted the base well with a sharp Yolkman's spoon. The 
tissues broke down somewhat deeper under curetting, but 
to the eye were normal in colour. I afterwards had some 
doubts whether I had done wisely in not removing the 
whole of the supra-vaginal portion of the cervix, and 
therefore a few days afterwards applied chloride of zinc. 
A deep slough resulted, and the patient was discharged in 
a few weeks with the p^irt all but healed and apparently 
free from disease. 

The portion removed, which embraced the whole diseased 
part so far as the eye could judge, was hardened in Miiller's 
fluid, and as much as possible being preserved, sections 
were made. 

The part not so used is now on the table. It is much 
shrunk, but shows the depressed surface of the diseased 
portion. When freshly removed it included the bottom or 
deepest part of the visible disease, but as the result 
of microscopic examination there can be no doubt that the 
whole of the disease in depth was not removed as I thought 
at the time. Probably as the curette was very freely 
used the whole was subsequently removed. 

Sections of the ulcer, for growth it cannot be called, 
show it to be glandular, or an adenoma. The new gland 



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210 ADENOMA OF THE FOBTIO YAGINALI8 UTEBI. 

tissne^ however^ is almost everywliere lined with one layer 
only of epithelium^ and contrasts so much with undoubted 
malignant adenoma that the idea occurs to me that pos* 
sibly adenoma in the uterus may not^ as supposed^ be in- 
variably malignant^ or at any rate that there may be a 
form of it which is merely bordering on malignancy. 

The accompanying coloured drawing is nearly as good 
as a photography and is accurate almost line for line^ as the 
artist who did it has a plan of projecting the microscopic 
view on to the paper^ where it is copied accurately. 

In order to show the difEerence between this and 
genuine malignant adenoma of the uterus, it may be well to 
compare it with similarly executed drawings from another 
and undoubtedly malignant case. In these the prolifera- 
tion of epithelium is very marked. The original slides 
are before you that you may judge of the accuracy of the 
drawings. The main clinical fact which makes this case 
peculiar is the absence of any up-growth, the diseased 
surface being, indeed, below the general level. It had, 
judging by the history, existed for two years, and still 
had spread but little. In its clinical features, therefore, 
it seems to bear almost the same relation to true adenoma 
that rodent ulcer does to cancer. The patient has been 
recently examined, and there is no return of the disease. 

Dr. Daxin thoi^ht that everyone would agree with Dr. 
Braithwaite that his case was of an adenomatous nature, but 
from the description of the clinical appearances, of the micro- 
scopic sections, and from the history and subsequent events, it 
was difficult to see the distinction between the case in question 
and one of erosion of the cervix. The fact that there was a 
depression was possibly an accident, and due to the erosion 
having appeared over an area alreadpr depressed, seeing that the 
woman was a 3-para. The histological appearances were those 
of an erosion, namely, sections of numerous glands like those 
of the cervix, and not showing any sign of commencing malign 
nant action. 

Dr. Amand Boxtth alluded to the well-known fact that a 
cervical adenoma was extremely prone to become malignant 
through proliferation of the columnar cells lining the acini, and 
it was possible that this change had occurred in that portion of 



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ADENOMA OF THE FOBTIO VAGINALIS UTEBI. 211 

the adenoma where the ulceration had been seen, although the 
microscope did not prove it. 

The I^EsiDENT said that Dr. Braithwaite's case was a very 
unusual one, and an obscure one. Had it not been that the 
surface of the ulcer was depressed, he thought everjone would 
bave thought it an ordinary erosion. The microscopic struc- 
ture resembled that of an erosion ; there was no infiltration, 
and there was no statement that the patient had wasted. 



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JULY 4th, 1894. 

Gr. Ernest Herman, M.B., President, in the Chair. 

Present — 43 Fellows and 3 visitors. 

Books were presented by the Middlesex Hospital Staff 
and La Society Obstetricale et Gynecologique de Paris. 

W. Gilbert Dickinson, L.E.C.P.Lond. ; Thomas Vincent 
Dickinson, M.D.Lond. ; Bernard P. Hartzhorne, M.E.C.S. ; 
and Hugh Playfair, M.D., were admitted Fellows of the 
Society. 

The following gentlemen were elected Fellows : — ^Boland 
Danvers Brinton, B.A,, M.D.Cantab. ; David Fairweather, 
M.D.Edin. ; John Amallt Jones, L.E.C.P.Lond. (Aberavon) ; 
Albert William Denis Leahy, M.D.Durk, F.E.C.S.Eng. 
(Calcutta) ; -^neas John McDonnell, M.B.Sydney (Queens- 
land) ; and David Petty, M.B., C.M.Edin. 

The following gentleman was proposed for election : — 
Robert Kingdon Ellis, M.B., B.Ch.Oxon. 



: THE MENSTEUATION OF 8EMN0PITEECU8 
ENTELLUa. 

By Walter Heafe, M.A., 

ZOOLOOICAX KUBBUKB, CAKBBIDOS. 

. I HAVE been invited to lay before you this evening a 
few sections demonstrating the process of menstruation in 



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214 HENSTBUATION OF SEMNOFITHECUS INTELLUS. 

S. entellus, and at the same time to make some remarks 
upon the work I have lately done on the subject. 

In the first place I should perhaps lay before you 
some evidence to show that menstruation does actuaUy 
take place in monkeys. 

Geoffrey St. Hilaire and Cuvier found that in three 
different species there was a regular monthly discharge of 
blood from the generative organs; these species were 
Cercopithecus, Macacus, and Cynocephalus. 

Mr. Bartlett, Superintendent of the Zoological Gardens 
here^ informs me that monkeys kept in the gardens men- 
struate^ and Mr. Sutton^^ who has published an account 
of his researches on the process in M. rhesuSy states that 
this species menstruates fairly regularly. 

It is, of course, highly probable that tropical or semi- 
tropical animals when brought to England will suffer 
from derangement of physiological processes, and it would 
not therefore be surprising to find that the regularity of 
such a process as menstruation is interfered with, to some 
extent, in individual monkeys when kept in confinement 
here. From the description given by Mr. Sutton I can 
only conclude that in the animals he examined some such 
derangement had occurred, for when in Calcutta I kept 
a considerable number of these animals alive, and found 
that menstrual phenomena were exhibited with remarkable 
regularity. I have also kept M. rhesus in Cambridge for 
a short time, and two of the specimens in my possession 
menstruated regularly for three months. A flow of blood 
from the vagina was observed to last from three to five 
days, and the mean dates were^ in specimen (a). May 7th^ 
June 2nd, and July 6th; in specimen (6)^ May llth, 
June 11th, and July 6th. 

Mr. S&ny&l, the Superintendent of the Zoological 
Crardens at Calcutta, assures me that all monkeys men- 
struate regularly there, and I myself observed the pheno- 
menon in a specimen of Cynocephalus porcarius for two 
months, and' in a specimen of Jf. cynomolgus for three 
* ' Brit. Oynncolog. Jonrn./ vol. ii, 1880. 



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MENSTRUATION OF SEMNOFITHECUS ENTELLUS. 215 

znonths; the latter specimen exhibited a flow of blood 
from the vagina on December 20th^ January 20th^ and 
about February 20th. Finally, with regard to 8. ert- 
telliLS, I satisfied myself that those animals which were 
kept under observation, menstruated each month from 
January until April, and that the flow of blood from the 
vagina lasted about four days. 

At the time the material for this work was collected the 
breeding season for S, entelltcs was practically over, only 
a few specimens being found in which evidences of recent 
delivery were shown. In order to guard against the con- 
fusion of phenomena connected with pregnancy and those 
solely due to menstruation, special care was taken that no 
specimen should be used for this work in which the 
mammary glands gave any evidence of lactation, or in 
which the uterus was of abnormal size or consistency. I 
may add that the uteri of such animals as had recently 
borne young were readily distinguished from menstruating 
uteri by their size, consistency, and the colour of their 
mucous membrane ; they were much larger, much softer, 
and more flabby ; the muscular coat showed decided signs 
of having been stretched recently, and the mucous mem- 
brane was very soft and of a yellowish brown colour. 

The external signs of menstruation are very variable in 
extent in monkeys. An enlargement of the vulva and of 
the nipples is invariably seen ; and in 8. enlellusy where 
these parts are coloured black, this is the only sign I have 
observed to accompany the discharge of blood. In Jf. 
rhestuf, however, the nipples and vulva are not only 
swollen but they are highly congested and assume a deep 
red colour, while the skin of the buttocks, which is 
wrinkled and hard during the intermenstrual period, be- 
comes during menstruation, soft, swollen, tense in fact and 
most brilliantly red in colour ; further, the abdominal wall 
for a short distance upwards, the inside of the legs as far 
down as the heel in some cases, and the under surface of 
the tail for more than half its length are also coloured a 
vivid red. 



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216 MENSTRUATION OF SEMNOFITHECUS ENTELLUS. 

In the baboons tbe swelling of the bare skin of the 
buttocks is enormous ; a specimen of the Chacma baboon 
(0. porcarius), which I had an opportunity of seeing in the 
Calcutta Gardens, evidently suffered very considerable in- 
convenience at such times ; the orifice of the vagina and 
rectum were nearly closed altogether, the skin seemed 
swollen almost to bursting point and resembled both ixx 
tensity and colour a huge tomato ; the care with which 
the animal sat down showed plainly enough that these 
parts were very tender. 

In connection with this subject the nervous communica- 
tion between the flushed area on the buttocks, thighs, and 
tail of M. rhesus, and the vagina, is of interest. Langley 
and Sherrington* have demonstrated that the motor roots 
of the first, second, and third sacral nerves supply the 
vagina, while the sensory roots of these same nerves supply 
the skin of the flushed area described above. 

The menstrual discharge from the vagina of 8. entelUis, 
M, rhesus, and M, cynomolgus consists of a white, stringy, 
mucus-like material ; together with blood-corpuscles, squa* 
mous epithelial cells, columnar epithelium, and connective- 
tissue corpuscles in variable quantities and proportions. 
The discharge from the Chacma baboon I was unable 
to obtain for examination, as the animal was very savage, 
but it was noticeable that the discharge was more of 
an opaque white and less coloured with blood than in 
the other species of monkey. Whether the enormously 
swollen aud deeply congested tissue around the genital 
opening of this baboon has the effect of withdrawing from 
its uterine tissue a considerable proportion of the blood 
which would otherwise serve to congest its menstruating 
mucosa I am unable to say, but it would seem to be not 
altogether improbable such is the case, and that the amount 
of menstrual blood discharged may be to some extent in- 
versely proportionate to the amount of swelling and con- 
gestion of the external parts. 

: I have for convenience divided the various phenomena) 
• 'Joom. of Physiology/ vol. xii« 1891. 



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MENSTRUATION OF SEKNOPITHECUS ENTELLUS. 217 

which take place in the uterus of 8. entellus during men- 
struation^ into four periods, and have subdivided the 
periods into eight stages ; and, as the preparations under 
the microscopes will show, these periods and stages are 
very readily demonstrable ; they are as follows : 

A. Period of rest. Stage I, the resting stage. 

B. „ growth. Stage II, growth of stroma. 

Stage III, increase of vessels. 

C. „ degeneration. Stage IV, breaking down 

of vessels. 
Stage V, formation of lacunas. 
Stage VI, rupture of lacunae. 
Stage VII, formation of the 
menstrual clot. 

D. „ recuperation. Stage VIII, recuperation 

stage. 

The uterine mucosa has the appearance of a very 
primitive tissue and, as I shall endeavour to show, it per- 
forms the functions of a primitive tissue. It consists of 
an epithelium of a single row of cubical cells, continuous 
with the epithelium of numerous straight, rarely branching 
uterine glands which are embedded in the subepithelial 
layer or stroma, as I have called it. The stroma is prac- 
tically of the nature of a plasmodium, a vast number of 
nuclei are connected together by protoplasmic processes 
which form in the quiescent, intermenstrual period a 
loose network. There is in this tissue no indication of 
separate cells, the protoplasm surrounding one nucleus is 
continuous, by means of its thread-like processes, with 
similar processes formed of the protoplasm surrounding 
neighbouring nuclei, the whole forming a loose network 
in which blood-vessels and glands are embedded. The 
stroma is bounded on its superficial side by the uterine 
epithelium and on its lower side by the inner circular 
muscle layer of the uterine wall, and it is the stroma 
which is chiefly concerned in the process of menstrua- 
tion. 



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218 MENSTBUATION OF SEMKOPITHECnS EKTELLUS. 

From the inner circular muscle layer a few radial 
muscle-fibres branch off here and there into the stroma^ 
but otherwise these layers are sharply separated the one 
from the other. 

The mucosa which, during the quiescent intermenstrual 
period has the appearance of a soft, semi-transparent, 
loose tissue, becomes first swollen during Stage II owing 
to the growth of the stroma by the multiplication of its 
nuclei in the superficial region, and thus assumes a denser 
and more opaque appearance ; it then becomes congested, 
its blood-vessels increasing first in number and then in 
size (Stage III), and this causes the flush, which is very 
noticeable when a uterus of this stage is first cut open. 

Later (Stage IV), the vessels in the superficial part of 
the stroma become first hypertrophied, then degenerated, 
and finally they break down, the blood contained in them 
being extra vasated into the meshes of the stroma network. 

Gradually the extravasated blood collects into lacunas, 
which increase greatly in size and eventually come to lie 
close beneath the uterine epithelium (Stage V) ; this 
stage may be diagnosed, when examined superficially, by 
the presence of specks of a dark red colour scattered 
about on the flushed surface of the mucosa, and by the 
absence of any free blood in the uterus, while histological 
examination further shows hypertrophy and degeneration 
of the superficial portion of the stroma tissue. 

I would here draw attention to the fact that it is on 
the dorsal side of the uterus that these specks first make 
their appearance, and that it is the dorsal lobe of the 
placenta of these monkeys which is first developed in 
pregnancy. 

The presence of free blood in the uterus is the next 
step in the progress of menstruation (Stage VI) ; it is 
caused by the rupture of the lacunas and the pouring out 
into the cavity of the body of the uterus, of the blood 
contained therein. While finally (Stage VII) the men- 
fitrual clot is formed of this blood, together with masses 
of stroma tissue, pieces of uterine glands and capillary 



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MENSTRUATION OF SEMNOPITHECUS BNTELLUS. 219 

vessels — ^largely degenerated tissue— which is torn away 
from the uterine wall by the rupture of the lacunas and 
the rush of blood from the torn vessels. It is noticeable 
that only the superficial third of the stroma layer is thus 
cast off. I have been unable to distinguish characteristic 
decidual cells in any part of the tissue which is thus shed^ 
and have on that account adopted the term introduced by 
Wyder*, viz. menstrual mucosa, to describe it ; instead of 
the term menstrual decidua, which is used by many authors 
to denote the menstrual tissue of the human subject. I 
should also mention here that there does not appear to be 
any very considerable flow of mucus from the uterine 
glands, and that a clot is always found, in some cases of 
considerable size, within the uterine cavity at this stage. 

Before the clot is expelled from the uterus the recupe- 
ration (Stage VIII) begins. A fresh epithelium grows 
over the torn surface; at first it is formed of flattened 
cells, and these gradually assume a columnar form. New 
vessels are formed, which eventually communicate with 
those already existing in the deeper parts of the stroma, 
and after the menstrual clot has disappeared the stroma 
itself gradually shrinks, drawing after it the newly formed 
epithelium, and assumes again the proportions and con- 
sistency described for the inter-menstrual period, i. e. 
Period A. 

There are several facts of considerable interest con- 
nected with this recuperative process, such as the relation 
of the upper and lower parts of the stroma, the changes 
which take place in the nuclei and protoplasm of the 
stroma, the flow of blood, the formation of the epithelium, 
the reclamation of extravasated blood in newly formed 
vessels and the method of the formation of those vessels, 
and the behaviour of leucocytes ; to all of which I have 
paid some attention. I will, however, here mention only 
the last three. 

First, the formation of the epithelium. Some of the 
epithelium is undoubtedly derived from the torn edges of 
• ' Arch, f . GynsBkologie/ vol. xiii, 1878. 



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220 HENSTBUATION OF SEMNOPITHECUS ENTSLLU8. 

the epithelium of the portions of such glands as remain 
embedded in the deeper parts of the stroma after the 
menstrual mucosa has been cast ofE, and here it is formed 
by the division and multiplication of the cells of the 
pre-existing epithelium ; but other parts of the new 
epithelium are formed in regions where there are no 
glands remaining, and from whence the original epithe- 
lium has been cast off. Here stroma cells may be 
observed which, becoming flattened, take upon themselves 
the character and function of epithelial cells, and they 
fuse with those portions of the same layer derived from 
the glands, and form a continuous uterine epithelium over 
the whole surface of the mucosa. 

. Secondly, the reclamation of extravasated blood-cor- 
puscles in newly formed vessels. When the new epithe- 
lium is formed over the torn surface of the mucosa, great 
numbers of extravasated blood-corpuscles, which are at 
the time lying amidst the meshes of the superficial part 
of the remaining stroma, are also enclosed, and I find they 
are neither absorbed nor degenerated, but are reclaimed 
and returned to the circulatory system. Wherever a group 
of such corpuscles, or even a single corpuscle, is seen lying 
free in the stroma, there a vessel is formed more or less 
minute according to the number of blood-corpuscles 
requiring to be included. The vessels are formed from 
the stroma tissue which immediately surrounds the free 
blood-corpuscles ; the protoplasmic processes become flat- 
tened and joined together to form capillary vessels, which 
eventually communicate with those pre-existing in the 
deeper part of the stroma layer, whose superficial loops 
have been torn away. This method of the formation of 
capillaries has not, as far as I have been able to discover, 
been recognised in any adult mammalian tissue. 

The capacity of the stroma tissue to form new epithelium, 
new glands (for new glands are formed by the folding 
inwards of the newly constituted epithelium), and new 
vessels, in short the great recuperative power exhibited 
by the indifferent elements of the stroma, indicates the 



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MENSTBXTATIOK OF SEMKOPITHECCJS ENTELLXTS. 221 

elementary nature of that tissue. The history of the deve- 
lopment of the uterus shows that this organ with its epithe- 
lium^ glands^ and vessels^ is derived from one and the 
same embryonic layer, the mesoblast^ and it is of great 
interest to observe that the renovation of these parts is 
possible at all times from the stroma itself. The circum- 
stance points, in my opinion, to the retention by the 
stroma of embryonic powers, powers which are probably 
retained in consequence of the regular and persistent 
calls for growth and recuperation to which the tissue is 
subjected. 

The third point I would mention is the behaviour of the 
leucocytes. A great increase of leucocytes is observed in 
the vessels of the mucosa during their congestion and 
during the period of degeneration (Period C). When the 
vessels break down and the blood-corpuscles are scat- 
tered amidst the stroma, these leucocytes cling to the 
remnants of the walls of the vessels. Some of them, it is 
true, are washed out with the blood-corpuscles into the 
surrounding tissue, but these are few in number; the 
great bulk of leucocytes attach themselves to the remnants 
of the torn vessels. If, as happens in the superficial part 
of the mucosa, these vessels are included in the tissue cast 
off to form the menstrual clot, the leucocytes are also cast 
off, but great numbers of them remain clinging to those 
portions of the vessels which are retained in the sub- 
menstrual mucosa, and these are, like the blood-corpuscles 
themselves, reclaimed and sent back to the circulatory 
system. They take no part in the formation of new 
tissue, they do not form pus on the wounded surface, and 
they at no time migrate voluntarily into the surrounding 
tissue. This behaviour of the leucocytes is, I think, not 
without much interest; whatever may be the cause of 
their increase in number, whether it is the presence of irri- 
tating material in the blood, as Metschnikoff's researches''^ 
would seem to indicate, or whether from any other of the 
various causes suggested by other observers^ the fact 
* ' Lemons sor la Pathologie compart de rinflammation/ 1892. 

VOL. XZZVI. 16 



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222 ^NSTBUATION OF 8EHK0PITHECUS ENTfiLLUS. 

remains that they apparently do little when they are there, 
and that they are eventually sent back from whence they 
came. 

There seems much to be said for MetschnikofPs views, 
supported as they are by his admirable experimental 
work; he may briefly be said to urge that it is the 
presence of an inflammatory substance in the blood or in 
the tissues which draws leucocytes to the parts so affected 
for the purpose of absorbing the irritating material. If 
the irritant be in the blood the leucocytes remain in the 
vessels, if it be in the surrounding tissue the leucocytes 
migrate from the vessels into that tissue and attack the 
irritating material in situ. 

In this instance — menstruation — ^the leucocytes do not 
migrate into the tissue, they remain in the vessels, so that 
it may be inferred the irritant is in the blood, and I would 
suggest it is owing to the fact that large quantities of 
blood are expelled out of the body vi4 the generative 
canal, that the irritant is in that manner lost and the 
presence of the leucocytes rendered unnecessary. 

With regard to the origin of this irritating material, the 
evidence at our disposal appears to point strongly to the 
probability that it is produced locally, while the congestion 
of the vessels and the degeneration of the tissue of that 
part of the mucosa may be urged to be sufficient cause 
for the production of the irritant. 

If, from any cause, menstruation does not take its usual 
healthy course, the leucocytes will probably have their 
work to do, but I am ignorant of the histological changes 
which take place during abnormal menstruation, and do 
not venture any opinion as to what their action may be 
under these circumstances. What does appear to be 
highly probable is, that the irritant which is presumably 
present in the blood is thrown off, together with the 
mucosa menstruaUs, in the menstrual discharge, and that 
nothing of it remains during the recuperation stage. 

Finally, I would suggest that sufficient stress has not 
been laid upon the four periods of the menstrual cycle. 



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MENSTBUATION OF SEMKOFITHEGUS BNTELLUB. 223 

and that a consideration of them, although it does not 
explain the origin, yet it leads to an explanation of the 
function of menstruation which is in accord with the 
opinions of a large proportion of the gynaecologists of the 
present day ; this function .being, the expulsion of tissue 
which is produced by a growth of the mucosa at certain 
regular periods, when that tissue is not required for the 
purposes of gestation. In conclusion, I will merely add 
that I am unacquainted with any natural process through- 
out the animal kingdom which can compare in severity 
and completeness with this periodic menstrual phenomenon. 

Mr. Alban DosAir asked if Mr. Heape had discovered which 
were the lowest of the mammalia where menstruation, or some 
phenomenon clearly homologous to it, could be observed. Even 
m man the catamenia were influenced by climate. The results 
of medical exploration amongst the northernmost Esquimaux, 
recently read before the New York Obstetrical Society,* de- 
served consideration. During the long Arctic winter total sup- 
pression of the catamenia was normal. The sexual passion was 
also suppressed, in the men as well as in the women, at that 
season. The significance of the changes in the endometrium in 
SemnopUhecus erdeUuB desenred consideration. That mucous tract 
was, as Mr. Bland Sutton had shown, of simple structure in that 
monkey, yet it underwent important changes. These changes pro- 
bably meant that the uterus must be kept constantly ready for the 
development of the decidua after impr^nation. The foetal Semno- 
pithecus, belonging to a high type, had to pass through compli- 
cated developmental changes before birth, which demanded a 
correspondingly complicated system of appendages to foster it. 
The endometrium repeatedly started these changes on its own 
part, but if impregnation did not occur it was partly shed and 
the process began again. In lower types of life a complicated 
nidification was not needed, hence menstruation, a part of that 
process, did not occur. 

Dr. G-BiFFiTH said that in their main features the microscopical 
characters of the sections exhibited by Mr. Heape were identical 
with those of human uteri which he had examined, and in this 
respect he differed from Mr. Bland Sutton's remarks. 

Dr. Amand Bouth alluded to the great difference which Mr. 
Heape had shown to exist, in this monkey at all events, between 
repair of wounds in the uterine lining membrane as compared 

* Dr. Frederick Cook, ' Newr York Journal of Gynecology and Obstetrict,' 
Harch, 1894, p. 282. 



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224 MEKSTBUATION OF SEHNOFITHSCUS ENTELLUS. 

with repair of skin or of other mucous membranes. If it was a 
fact that the epithelium and glands of the uterine lining mem- 
brane could be replaced from cells of the '' stroma " or sub- 
mucous layer, it would go far to explain the rapidity with which 
the membrane was restored after scraping even with a sharp 
curette, for the membrane seemed to be grown a^ain between 
the next and subsequent periods, and occasionally had again 
become redundant in three or four months, even to the extent of 
requiring another curetting. 

The President said he was sure he expressed the unani- 
mous feeling of the Society in thanking Mr. Heape for coiping 
among them that evening, and exhibiting and describiug the 
beautiful series of preparations that were before them. The 
subject they illuminated was of the greatest importance, lying 
at the very foundation of minor gynsecology. We had at present 
hardly any knowledge of what took place in the human uterus 
during menstruation. One authority said the whole mucosa 
was cast oft, others that only a part of it came away, and others 
that it remained entire throughout the process. There seemed 
to be similar differences in the results derived from observations 
on animals. Mr. Bland Sutton had found that in macaques 
there was no loss of substance in the uterine mucous membrane 
during menstruation. Mr. Heape found that in the enteUiis part 
of the mucosa was shed. These results were not contradictory, 
for the process might be different in different animals. Mr. 
Sutton's observations were made on monkeys living in confine- 
ment, and in a climate unnatural to them, and so perhaps might 
represent an abnormal condition. He (the President) hoped 
Mr. Heape would state the number of observations he had made, 
the circumstances in which the animals examined had been 
living, and whether they were all healthy or not. 

Mr. Heafe, in reply to the questions of those present, gave a 
brief description of the signs of menstruation exhibited by the 
monkeys which he kept under observation both in the Zoological 
G^dens in Calcutta and in Cambridge, and mentioned the 
swelling of nipples and vulva, and the existence of a bloody dis- 
charge, lasting about four days, which recurred with remarkable 
regularity in individuals of the species Semnopithecus, and in 
two species of macacus as well as in Cynocephalue jporcaritu. 



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225 



UTERINE FIBROID UNDERGOING COLLOID 
DEGENERATION, 

By T. G. Stevens, M.D. (for Petbb Horeocks, M.D.). 

Dr. T. G. Stevens showed for Dr. Horrocks a fibroid 
tumour in the anterior wall of the uterus, undergoing 
mucoid or possibly colloid degeneration, and simulating 
ovarian cystoma and pregnancy. 

The patient, aged 45, married and had borne children, 
two years ago became irregular and missed her periods, 
sometimes for three months at a time, and at the same 
time her abdomen began to swell. She was thought to 
be pregnant, and after waiting some time after labour 
ought to have supervened, she was admitted into a country 
hospital for an attempt to be made to clear the uterus. 
This failed, and she was then sent up to Guy's and admitted 
under the care of Mr. Lane. Now, the case presented 
clinically a large tumour, almost fluctuating and possessing 
a thrill, and in fact apparently an ovarian cyst. Abdo- 
minal section was advised and performed, but the tumour 
was found to be uterine. A more thorough examination 
could now be made, and owing to the peculiar degeneration 
of the tumour, a sensation as of solid lumps floating in a 
more or less fluid medium was found, and was strongly 
suggestive of a pregnant uterus. The operation was aban- 
doned, and the patient made a good recovery. Dr. Horrocks 
was now called in to see what could be done with the 
contents of the uterus. He found the os uteri very high 
up and the cervix elongated; the sound passed seven 
inches. After dilatation with tupelo and laminaria tents, it 
was just possible to introduce the finger within the internal 
OS uteri. Then the lower end of the tumour in the ante- 
rior wall could just be felt, and the uterine cavity was 
apparently empty. Dr. Horrocks then again advised opera- 
tion, and removed the whole mass by abdominal hysterec- 



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226 UTBEINE FIBROID UNDERGOING COLLOID DEGENERATION. 

tomy, using the serre-noeud and fixing the stump in the 
lower angle of the wound. Up to the present time the 
patient is doing well. The tumour consisted of a uterus 
with a dilated cavity and elongated cervix, with a large 
tumour in the anterior wall. The anterior wall was ex- 
panded and thickened over the tumour, forming a kind of 
capsule. The tumour itself consisted for the most part of 
solid fibroid material, with here and there large areas of 
mucoid substance. 

Microscopically the tumour was a fibro-myoma, and the 
degeneration could be seen as affecting the fibrous tissue, 
giving rise to a cloudiness and loss of fibrillation, with here 
and there rounded spaces as if some material had fallen 
out. 

Dr. Horrocks was indebted to the courtesy of Mr. Lane 
for the privilege of showing the specimen. 



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227 



REMAEKS ON FCETAL RETROFLEXION : REPORT 
OP A SPECIMEN SHOWING ORIGIN OF 
GLUTEUS MAXIMUS FROM OCCIPITAL BONE. 

By Lbonabd Rempey, M.A., M.D., B.C. (Cantab.), 

▲BSIBTAITT 0B8TBTBIC PHYBICIAIT AND ASSISTANT LECTUBEB OV OBSTBTBIO 

MBDICmB AT ST. GBOBGB'S HOSPITAL; OBSTBTBIO PHT8ICIAK 

TO THB OBBAT NOBTHBBN OBNTBAL HOSPITAL. 

(Received May 24th, 1894.) 
{Abstract.) 

Db. Remfby discussed the causes of retroflexion as given by 
various authors, and divided them into (1) abdominal, (2) dorsal. 
(1) The abdominal were those in which either there was no cord 
at all — a condition generally associated with ectopia visoerum, — 
or in which the cord was present but short, a backward flexion in 
both instances being produced, with the placenta as the fixed 
point. (2) The dorsal causes belonged to various abnormalities 
of the vertebral column : (a) failure in development of spine as a 
whole, due to deficiency of spinal medulla ; (h) imperfect con- 
struction of one or more bones ; (c) absence of vertebraa ; (d) any 
weakness of the spine from any cause whatever. In (1) the 
absence or shortness of cord was the essential element ; in (2) 
the imperfect spinal axis. 

In the case reported the flexion had taken place at the 
occipito*atloid joint; the occiput, which was incompletely 
developed, being bent over so that the posterior part of the head 
nearly touched the crests of the ilia. There was some latere- 
flexion to the left, and on this side the gluteus ma7«mn« '^'^^ 
seen to have a distinct origin from the upper port 
occipital bone. On the right side an encephalocele 
about three cubic inches separated the occipital bone 
crest. 

Various other abnormalities were commented on, a 
plete dissection of the specimen detailed. 

The foetus was full time. The presentation was pel 
longed traction effected delivery, but only after som( 



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228 F(ETAL BXTBOfLEXION. 

felt to liaTe giyen way. This afterwards was f ouDd to be the 
cord, which was two inches long. The author was indebted to 
Dr. Hincks, of Haj, for the interesting specimen.* 

Bbtboflkxiok of the foetus is a condition of great 
interest, and every specimen of the kind is sure to repay 
careful examination. 

In this paper the object is to bring forward details of 
a curious and, what is believed to be, a unique case with 
origin of one gluteus maximus from the left upper portion 
of an imperfectly formed occipital bone, and also to place 
together some of the views already expressed relative to 
the causes of retroflexion. 

First, to describe the foetus, for which I am much 
indebted to Mr. Hincks, of Hay. The labour was very 
tedious. When the patient was first seen, a foot could be 
felt in the vagina. The other foot was brought down, 
and after prolonged traction on both legs delivery was 
effected. During the process a snap was felt as of some- 
thing having broken. This was subsequently proved to 
be due to rupture of the cord, which was torn away at the 
umbilicus and remained attached to the placenta. It 
was two inches long. The child, which appeared to be 
full time, was dead. 

Examination. — External appearances. — ^With the bodyin 
the upright position, the face looks to the sky. The features 
are apparently normal, but the ears are corrugated from 
above downwards very considerably, and the insertion is like 
a button into a cushion. Beneath the chin there is a swell- 
ing one inch deep, reaching from one ear to the other and 
filling up the submental angle and the angle between the 
cheeks and shoulders. The head is retroflexed so that 
the posterior part of the skull comes into relation with 
the crests of the ilia — ^the hairy scalp being flush with 
the level of the buttocks and merging directly into the 
skin of those parts. On tracing the lower lateral boun- 
daries of the head, the thorax, the back of which the 
* This is in the masenm of the Rojal College of Surgeons. 



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FOSTAL BETBOFLEXIOK. 229 

Head completely covers, is also flush with the side of the 
head. On the right side and overhanging the right crista 
ilii is a collapsed sac which springs from the junction of 
the lateral and posterior aspects of the head, and from 
a large orifice in which brain matter exudes freely on com- 
pression of skull. This sac when distended would pro- 

Fio. 1. 



bably contain 2^ to 8 cubic inches. There is no hair over 
the sac. On passing a finger through the opening it is 
found to enter a large cavity, the boundaries of which 
are cranial bones, which appear to be entire except in the 
situation of the lower portions of the occipital. The dia- 
meters of the head are : mento-frontal 2} ; binaural 2^ ; 
biparietal 2} ; forehead buttock 4| ; bitrochanteric 2|. 

In the situation of the umbilicus there is a rounded and 
hard boss on the right side, and on the left is a fibrous 
cord the thickne&s of a digital nerve (f umbilical artery). 



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2S0 F<ETAL BETBOFLEXIOK. 

and some shreds of tissne not at present obvious. The 
upper part of the boss is covered with fairly well formed 
skin. The legs and arms are normal. The external 
organs of generation are those of a female^ the hymen 
well developed. The central line of the perinsBum is not 
covered with skin. To represent the anus^ which is on a 
level with the brim of the pelvis, there is a hole in the 
skin. On looking deep down into this hole is seen another 
smaller one at the commencement of a tube (f intestine). 
(At a later stage of examination the tube was found to be 
the rectum, i. a. the anal involution had not joined the 
gut.) 

FiQ. 2. 



A. Thyroid. B. Thymns. C. Heart. D. Diaphragm. E. Long. 
Left long not shown. 

On opening the thorax, the following are seen from 
above downwards: — ^The thyroid, measuring 1 by 1^ inches; 
the lobulated yellowish-white thymus, measuring If by 
i inch ; the intensely pink lungs, showing no appearance of 



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^(ETAL BETBOFLEXION. 231 

respiration having occurred, overlapping the heart ; lastly, 
the arching diaphragm. The thyroid, on being removed, is 
found to consist of four lobes — ^two principal middle lobes 
and two small lateral ones (microscopically the structure was 
normal). The thymus was weighed, and scaled 19 grains. 

On opening the abdomen, the liver is very large, and 
of a curiously irregular shape. At its lower edge projects 
a pedunculated portion, the size of a large cherry, into a 
cavity of amnion which was described as a prominence on 
the abdominal wall. The liver is adherent, above to the 
diaphragm and at the sides to the abdominal walls. 

On removing the skin of the back and dissecting further, 
the gluteus maximus on the left side is seen to have an 
extra origin from the left upper part of an imperfectly 
developed occipital bone. 

The specimen has been dried in order to show the 
exact original position of the head and the excessive 
flexion of the cervical on the dorsal vertebreB. The head 
is rather on one side, owing to the encephalocele having 
protruded from the right side and levered it to the left. 

The doubling over of the cervical vertebrae, and the 
resting of the head upon them when the foetus is lying on 
its abdomen, are well shown. 

Description of skeleton by Mr. Stonham. — 8hull. — 
The facial, frontal, and parietal bones are normally deve- 
loped ; palate normal ; intermaxillary bones perfect. 

Occipital bone. — ^The basi-occipitals and ex-occipitals 
are developed. The tabular portion is represented by two 
crescentic curved plates of bone, separated by a large 
opening, bounded in front by the posterior margins of the 
parietals and partly closed below by the displaced spinal 
column. The opening is wider from side to side than from 
above downwards. The posterior fossa of the skull is 
consequently in great part formed by the posterior sur- 
face of the bodies of the vertebrae and by the spreading 
neural arches. 

The free margin of the right representative of the 
tabular occipital bounds the above-mentioned opening, but 



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282 r<ETAL BETBOFLEXIOK. 

anteriorly it comes almost into contact with the neural 
arches of the dorsal vertebrsB. On the left side the corre- 
sponding margin is in contact with the neural arches 

Fia. 8. 



£. Encephalocele. G.Max. Cat end of gluteus maximns. 
Fibres shown on occipital bono above. 

of the lower dorsal and lumbar vertebraB. On each side, 
but better seen on the left, a gap exists between the ex- 
occipital and the neural arches. This gap represents the 
jugular foramen. 

Temporal bone normally developed, and the three parts 
easily recognisable. On the left side the tympanic ring 



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FCETAL BSTBOFLSXION. 283 

is present. On the right it is absent, and the membrana 
tympani and malleus are disclosed. 

Spinal column. — ^The coccyx is absent, having been 
lost in maceration {vide lower surface of last vertebra). 
The bodies of the vertebreB cannot be accurately counted, 
since ossification is very irregular and many additional 
centres are present. 

There is complete spina bifida, the neural arches 
gaping widely, giving the posterior surface of the spine a 

Fig. 4. Fig. 6. 



Front view. Back view. 

boat-shaped appearance. From its articulation with the 
ex-occipitals the spinal column curves forwards on the 
basi-occipitals for a short distance, and then abruptly back- 
wards and somewhat upwards, so that the terminal vertebra 



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234 



FCETAL BETBOFLEXION. 



present (? last sacral) is distant about one inch from the 
posterior margin of the left parietal. In addition to the 
curvature mentioned, the whole column inclines to the left 
of the middle line, and hence the approximation (already 
noted) of the left neural arches to the left tabular occi- 
pital and the separation on the right side. 

Ribs. — Irregularly developed, especially on the right 
side, where they are represented by short columns of bone 
more or less welded together. On the left side eleven 
can be counted. Some of them are joined at their angles, 
and the seventh and eighth of the series are united at 

Pig. 6. 



Fig. 7. 



Bl. 




L.Uml 



their heads, forming a flattened plate, the whole having 
a V-shaped appearance. 

In the above general report of. the examination of the 
foetus, the abnormalities chiefly have been noted. The 
circulation, intestines, &c., not mentioned, were, however, 
carefully examined. 



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?(ETAL BETBOFLEXION. 285 

Remarks. — ^To come, finally, to the causes of foetal retro- 
flexion hitherto given. For the demonstration of these we 
are chiefly indebted to the papers of Dr. Matthews 
Duncan, Dr. Hurry, Dr. Dakin, and Mr. Lockwood. They 
may be spoken of as (1) abdominal and (2) dorsal causes. 

In cases in which there is no umbilical cord and the 
embryo is directly adherent to the placenta, — a, condition 
associated or not with ectopia viscerum, — ''there is a flexion 
on the fixed point, viz. the placenta,'* and the anterior 
and posterior extremities are pushed backwards. The 
same condition may be brought about by a very short 
cord, and probably the shorter the cord the greater the 
liability to ectopia. When the placenta is not in the 
median line, and there is no cord, lateroflexion is produced, 
but not necessarily in cases where there is at all events 
some cord. 

Then, retroflexion from dorsal causes may be due, as in 
the case of Mr. Lockwood's embryo, to some failure of 
development of the spinal column, owing, in his case, to 
deficiency of the spinal medulla, this in turn being the 
fault of the original epiblast from which the medulla is 
developed. An imperfect development of the spinal axis 
would, especially when the abdominal wall is firm and the 
contents of the abdominal cavity well formed as to bulk, 
tend to produce a dorsiflexion simply from a weakness of 
the vertebral column, which normally forms a support for 
the foetus as a whole. In fact, imperfect construction of 
this column introduces a hinge which is easily brought 
into play so that the parts above and below tend to be 
brought nearer to each other, and not suddenly so, but 
gradually during the embryo's slow growth. 

Absence of vertebrae will produce a flexion backwards 
at the deficient point, the vertebrae above and below tend- 
ing to approximate. If this absence be in the centre of 
the column, the upper and lower halves will approach one 
another equally. If it be in any other situation than 
central, then the shorter portion of the column will be 
more flexed than the longer. Thus, in the same way, if 



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286 FGBTAL RETROFLEXION. 

the occipito-atloid function be incomplete^ the head being 
the shorter arm of the lever should be ertremely flexed 
backwards. Such is the condition in the case described. 
As to the arrangement of the gluteus maximus^ ther^ is 
no doubt of its having been secondary to the retroflexion. 

Professor Macalister, remarking on the case^ says : 
'' There is no period of embryonic existence in which any 
condition like this is foreshadowed^ but there is this 
interest in it^ that the fore-limb homologue of the gluteus 
maximus (latissimus dorsi) is a spinal muscle^ and its leg 
arrangement as an iliac muscle is a secondary formation. 
They are both parts of a primitive superficial sheet of 
muscle stretching back from the somatopleura over the 
dorsal muscle^ and in this case the sheet has become dis- 
placed in consequence of the flexion/' 

In conclusion, it may be said that at the Royal College 
of Surgeons there is no specimen showing such a degree 
of retroflexion. 

Special thanks are due to Mr. Pooley for help in dis- 
section, and to Dr. Gouldsmith and Mr. Whistler for the 
drawing and photographs which illustrate the paper. 

Dr. Arthur Giles said there was one point in the remarks 
at the end of Dr. Remfiy's paper that seemed to invite a differ- 
ence of opinion, namely nis explanation of retroflexion as due to 
the failure of development of the spinal column. Was not this 
deficiency in the spinal column rather the result than the cause 
of the retrofiexion ? Dr. Bemfry explained the differences in 
position of the retroflexion as being produced by the different 
situations of the vertebral malformation. Dr. Giles suggested 
that the cause of retrofiexion was probably in all cases the close 
attachment of the foetus to the placental surface. The position 
in the uterus would determine the point of the foetus where the 
greatest curyature was found ; for example, if the attachment 
were in the middle of the long axis of the uterus, the upper and 
lower parts of the foetus would be fairly uniformly bent back, 
and the retrofiexion would be most marked in the dorsal region. 
If the attachment were higher up, near the fundus of the uterus, 
the head would be the part chiefly affected, and such an extreme 
condition as Dr. Bemfry's specimen exhibited might be pro- 
duced. Primary curvature or deficiency of the spinal column 
could probably not be produced except by disease of the vertebrse 



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FCETAL BETSOFLEXIOK. 287 

or their joints, and as far as lie knew such disease had not been 
found in these cases. On the supposition that the deficiency in 
the spine was secondary to the retroflexion, and that this in 
turn depended on the position of the fcetus in uteroy a uniform 
explanation of the co^idition was obtained. 

Dr. Amano Eouth thought tiie cause of the retroflexion here 
was the extreme shortness (two inches) of the cord, and this 
explained the fact that the retroflexion was at the junction of 
the cervical and dorsal regions. If the cause had beeii the more 
common one of the weight of extroverted abdominal viscera, the 
flexion would have been lumbo-dorsal, owing to the viscera 
dragging on the spinal column below the diaphragm. He 
wished to know the Reasons why it was thought that the inser- 
tion of the gluteus maximus into the left occipital bone was 
secondary to the retroflexion. He thought Dr. Remfry was 
right, because the lateroflexion was so slight, but he might have 
o&er reasons for his belief. 

The Pbesident said that Dr. Bemfry's paper was an excellent 
example of the use that should be made of malformed foetuses. 
Dr. Eemf ry had placed before them a careful dissection of the 
specimen, and an account of what was known of similar speci- 
mens. He (the President) found no difficulty in understanding 
how a very slight cause might produce extreme retroflexion of 
the foetus. The limitation of space in the uterus would lead to 
pressure on the two ends of the foetus. Normally this pressure 
favoured flexion, but if the foetus from any cause became so far 
extended that the occipito-spinal, or any spinal joint, became in 
front of the line along which the pressure on the two ends of the 
foetus was exerted, then this pressure would tend to more and 
more retroflex, that is extend, the foetus. In face presentation, 
which was often produced by slight causes, the extension was 
far greater than was ever seen in children after birth. Dr. 
Bemfry's specimen was in the attitude of a foetus presenting 
with the face. He agreed with Dr. Bemf ry that lateral flexion 
was present in his specimen. 

In reply, Dr. Hbmfby considered that Dr. Giles's theory 
that certain situations of cord and placenta might produce 
retroflexion was ingenious, but not very probable. Dr. Amand 
Eouth's question as to why it was thought that the insertion of 
the gluteus maximus was secondary to the retroflexion was a 
very difficult one to answer but the author had been entirely 
guided by Prof. Macalister, who said that the fore-limb homo- 
logue of the gluteus maximus (latissimus dorsi) was a spinal 
muscle, and its leg arrangement as an iliac muscle was a 
secondary formation. They were both parts of a primitive sheet 
of muscle, which in this case had become displaced in conse- 
quence of the flexion. 

VOL. XXXVI. 17 



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238 



TEMPERATURE IMMEDIATELY AFTER DELIVERY 
IN RELATION TO THE DURATION AND OTHER 
CHARACTERISTICS OF LABOUR. 

By Aethue E. Giles, M.D., B.Sc, M.R.C.P. 

(Received Jane Ist^ 1894.) 
{Abstract.) 

The author has analysed six hundred cases of normal labour 
from the point of view of the relation of the temperature after 
delivery to the characters of the labour. He concludes : 

1. The average rise of temperature due to labour is slight 
(average of six hundred cases, 98*7° : Tables I and II). 

2. The length of the first stage of labour bears a slight 
relation to the subsequent temperature (Table I and Chart III). 

3. The length of the second stage has a direct influence on 
the temperature, which rises in proportion to the length of this 
stage (Table in and Charts I and III). 

4. The time of day at which delivery takes place has very 
little influence on the temperature ; this is, however, highest in 
the groups of cases where delivery occurred between 12 and 
4 a.m., and between 4 and 8 p.m. (Chart 11). 

5. When chloroform is given during the second stage of 
labour the temperature is commonly low after delivery, even if 
the second stage last long. The average temperature in fifteen 
cases with a second stage averaging two hours and forty 
minutes was 987^. 

6. A similar result follows the application of forceps under 
chloroform ; in twenty-six cases with a second stage lasting, on 
an average, three and a half hours, the average temperature was 
98-8°. 

7. In twelve cases of natural delivery in which the second 



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TEMPERATURE IN RELATION TO THE DURATION OF LABOUR. 239 

stage lasted, on an average, thirty-fiye minutes, but where an 
intra-uterine douche was given, the average temperature after- 
wards was 99*4°. 

Having noticed incidentally that the temperature imme- 
diately after delivery was often higher after a long 
labour than after a short one, it seemed to me worth while 
to inquire if a constant relation existed. The necessary 
particulars were obtained from the case-books at the 
General Lying-in Hospital. 

Observations on " puerperal temperatures *^ have been 
presented already to this Society, viz. by Mr. William 
Squire* and by Dr. E. S. Tait.f But these two commu- 
nications deal mainly with the puerperium in general ; 
whilst I propose to restrict my remarks to notes on the 
temperature immediately after delivery, i. e, within about 
half an hour of the delivery of the placenta. 

I have analysed separately the temperature relations of 
the first and of the second stages of labour. For the first 
stage 300 cases were taken, and divided into seven groups 
according to the duration of this stage. The result is 
given in Table I, and in Chart III, 

Table I. 



Duration of 1st lUge 
of labour. 


4hoan 
or less. 


4-8 
boura. 


8-13 
boora. 


1»-16 
bonra. 


1«-S0 
boura. 


20-80 
.boura. 


Orer 

SOhoura. 


Total. 


No. of cases 

Average temp, 
after delivery . 


50 
98-44*» 


60 
98-6*' 


60 
98-76° 


60 
98-77*' 


30 
98-76° 


40 

98-87*' 


20 
98-82° 


810 
98-70° 



It will be seen from this table that the range of tempe- 
rature is very slight, amounting to only -j%®, and probably 
it would be even less were it not for the fact that when the 
first stage is very short the second is usually short also. 

• « Obstet. Trans./ vol. ix, for 1867. p. 129. 
t Ibid., vol. xxvi, for 1884^ p. 8. 



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240 TEMPERATURE IN RELATION TO THE DURATION OP LABOUR. 

And^ as we shall see^ the infinence of the second stage is 
well marked. 

The length of the first stage makes more impression on 
the temperature in those cases where the membranes 
rupture very early ; when this is so, and the first stage lasta 
one or several days, the temperature is often high, even 
when the second stage is rapid. I have also noticed 
several times that a long first stage in multiparsB is asso- 
ciated with a high temperature. The following readings 
illustrate these two circumstances. 

1. Temp.* 100*4^; membranes ruptured thirty hours- 
previously ; duration of second stage about thirty minutes* 

2. Temp. 99*2°; membranes ruptured sixteen hours pre- 
viously : duration of second stage thirty minutes. 

3. Temp, 99*6°; membranes ruptured twenty-three hours 
previously ; duration of second stage about ten minutes. 

4. Second stage of labour fifteen minutes ; temperature 
after delivery 100®; first stage twenty and a half hours. 
In a multipara. 

5. Second stage of labour twenty-five minutes ; tempe- 
rature after delivery 100°; first stage thirty hours. In a 
12-para. 

In tracing the influence of the second stage of labour, 
I have analysed the records of 600 normal cases. Eight 
groups were made, according to the length of the second 
stage, viz. 



1. 15 minutes or under. 

2. 15 — 30 minutes. 
8. 30—45 minutes. 

4. 45 minutes to 1 hour. 



6. 1 hour to H hours. 

6. li — 2 hours. 

7. 2 — 3 hours. 

8. 3 hours or more. 



In each group the number of cases was recorded at 
each degree of temperature, as in Table II. 

* Throughout this paper ** temperature " means " temperature immediately 
after delivery." 



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TEMPBBATUEB IN EBLATION TO THE DURATION OP LABOUR. 241 

Table II. 



DanUon of Snd stage. 


16 
nin. 


SO 
min. 


46 

min. 


Ibonr. 


1* 
hoori. 


3 
hours. 


8 

bonn. 


OrerS 
hours. 


Total. 


Temperature 97-0® 
972 
97-4 
97-6 
97-8 
98 
98-2 
98-4 
98-6 
98-8 
99 
99-2 
99-4 
99-6 
99-8 
100 
100-2 
100-4 
100-6 


8 
3 
3 

4 

5 

20 

14 

24 

20 

19 

22 

6 

6 

6 


2 

1 

3 

8 

4 

21 

8 

32 

24 

18 

15 

7 

5 

2 

3 

2 


i 
"i 

1 
8 
6 
7 

15 
4 

14 
6 
6 
5 
3 
2 

i 

1 


3 

*1 
2 
2 
3 
8 
5 
3 
5 
8 
5 
1 
1 
2 
2 


••• 

"i 

2 

8 
5 
7 
5 
4 
6 
4 
8 
5 
1 
3 
3 
1 


6 
3 
3 
4 
3 
2 
2 
1 
2 

"i 


"i 

2 

2 

1 
3 
4 
2 

4 

1 
1 

2 


4 

2 
3 
3 
5 
9 
2 
2 
3 
7 
1 
1 
1 


8 

6 

6 

15 

14 

64 

38 

85 

77 

55 

74 

47 

36 

27 

13 

19 

6 

3 

5 


Total 


155 


155 


81 


52 


63 


26 


23 


43 


698 




Average temp 98-5'' 


98-5° 


99*^ 


98-7® 


98-8® 


991° 


99-2® 


99-2® 


98-7® 



It will make this table clearer to condense it^ as in the 
following table. (Percentages in italics.) 





Table 


III. 






Duration of Snd stage. 


80 min. or 
less. 


80 to 60 
min. 


1 to 3 honri. 


OrerSbonrs. 


Temperature 97*2® 
97-8 
98-4 
99 
99-6 
1002 
100-6 


9 3 

27 8-6 

119 88-4 

118 88 

32 10-4 

6 1-6 


6 3-7 
6 8-7 
84 256 
46 84-6 
31 25-4 
10 7-5 
2 1-5 


3 '"8-8 

25 28-1 

26 28-1 
24 27-1 
10 11-2 

2 2-2 


9 "'l8'5 
17 26-5 
23 85 
13 20 

4 5 


Total 


310 100 


133 100 


89 100 


66 100 


Average temperature* ... 


98-5® 


98-8® 


98-9® 


99-2® 



* These averagei are calculated from Table II; if calculated from 



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242 TEMPSBATUBE IN RELATION TO THE DURATION OF LABOUR. 

Prom Table III is constructed the accompanying^Chart 
(I), which shows the same facts in graphic form. 

Chart I. 



A chart to show the prevalent ranges of temperature after labours of different 

duration. 

Curve a, heavy line. — Duration of 2nd stage of labour 30 minutes or less. 
Curve h, fine line. — Duration of 2nd stage of labour SO to 60 minutes^li 
Curve 0, dotted line. — Duration of 2nd stage of labour 1 to 2 hours. 
Carve d, interrupted line.— Duration of 2iid stage of labour over 2 hours. 
The vertical lines show the percentage of cases in each group at the corresponding 
temperature. 

Table III they are higher : €,g, cases at 98'6^ and 98*8^ would be merged in 
those at 99^; the averages in the four groups would then be 98*7^, 98*9**, 
99-1% and 99'tf'. 



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TEMPEBATUBE IN RELATION TO THE DURATION OF LABOUR. 24S 

It is thus clear that the duration of the second stage 
of labour has a definite influence, as a rule, on the tem- 
perature after delivery. 

Another factor has a slight influence, viz. the time of 
day at which delivery takes place. Shroeder states :* 
" Independent of the processes which immediately after 
labour cause a temporary rise of temperature to above 
39° C, it is chiefly the time of day at which delivery has 
taken place which determines the height of the tempera- 
ture. Its greatest rise takes place when the woman has 
been delivered in the course of the forenoon, because the 
normal daily and evening exacerbation then falls within 
the first twelve hours of the puerperal state. The suc- 
ceeding decrease is very considerable when delivery occurs 
in the first hours of the morning." To trace the effect of 
this factor on the temperature just after delivery, under 
conditions as similar as possible, I analysed 300 cases of 
multiparas in which the second stage of labour lasted less 
than an hour, dividing the twenty-four hours into periods of 
four hours each; 50 cases were taken of delivery within each 
period. The average temperature of each group of 50 
cases is given in Chart II. From this it appears that the 
highest average temperature occurred among the cases of 
delivery between midnight and 4 a.m. ; the average of 
those occurring between 4 and 8 p.m. was nearly as high. 
But the whole range of temperatures was very small, viz. 
12 midnight to 4 a.m. . . 99*" 



4 a.m. to 8 a.m. 


. 98-6'' 


8 a.m. to 12 noon 


. 98-6" 


12 noon to 4 p.m. 


. 98-7° 


4 p.m. to 8 p.m. . 


. 98-9° 


8 p.m. to 12 midnight 


. 98-6" 



The infiuence of this factor is therefore slight. 

* Schroeder, ' Manual of Midwifery/ English translation, London, Ib/d, 
p. 99. 



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244 TBMPEBATUBE IN BSLATIOK TO THE DUBATIOK OF LABOUB. 

Chabt n. 



A chart to show the relation of the temperature after delivery to the 
time of day at which deUvery occars. 

The oontinnouB line represents a four-hourly grouping of eases i 
the dotted line a two-hoorly. 

It will be seen from Tables I and II that the average 
temperature of all the 600 cases was 98*7^; the average 
rise is therefore not considerable. The number and 
percentage of cases at different temperatures is given in 
Table IV. 

Table IV. 



Temperntnre after 
delivery. 


No. 


Percentage. 


98-4** or below 

98-4° to 99^ 

99° to 100** 

Over 100 


286 

206 

142 

14 


89-4 

34-4 

23-7 

2-5 


Total 


598 


100 



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TEMPERATURE IN RELATION TO THE DURATION OF LABOUR. 245 



Thus nearly 40 per cent. Have a temperature at or 
below normal; about one third rise to 99^; nearly a 
quarter rise to 100° ; and only 2*5 per cent, go above 100°. 

The temperature after artificial or complicated delivery. 
— ^When chloroform is given the temperature after delivery 
is not usually high, even when the second stage of labour 
has lasted a considerable time. In 15 cases of primiparsB 
where chloroform was given to relax the passages and 
relieve pain, but where delivery occurred without instru- 
ments, the duration of the second stage and the tempe- 
ratures after delivery were as follows : 



No. 


Sod stage. 


Temp. 


No. 


Snd stage. 


Temp. 


1 


1 hour 


. 98*^ 


9 


.. 3 hours 


98-2° 


2 


... 1 „ 


98-8 


10 


.. 3 


»» 


... 98-4 


8 


... 1 b. 6 m. .. 


98-6 


11 


.. 3^ 


n 


99 


4 


li hours 


98-8 


12 


.. 4 


ft 


98-4 


5 


... U . 


99 


13 


.. 4i 


»» 


98-4 


6 


... 2 ,. .. 


98-2 


14 


.. 6i 


t* 


99-2 


7 


... 2i .. 


99-8 


15 


.. 5i 


ft 


99*6 


8 


... 2* .. 


98-6 











Or, 15 cases with an average duration of 2 hours 
40 minutes, second stage, had an average temperature of 
98-7° after delivery. 

Similarly, when the forceps are applied under chloro- 
form, after the second stage of labour has gone on a long 
time, the temperature is very seldom high ; this is shown 
by the following 26 cases. 



No. 


Duration, Snd itage. 


Temp. 


No. 


Dnration, Snd ttaKi 


1 


1 hour 


98° 


14 


3} hours . 


2 


... 1 „ 


98 


15 


.. 31 ,. . 


8 


... 1 „ 


98-4 


16 


.. 31 ., 


4 


... li hours ... 


98 


17 


.. 4 „ 


5 


... u ,. ... 


99 


18 


.. 4 „ 


6 


... 2 , ... 


97-4 


19 


.. 4 .. . 


7 


... 2 „ ... 


99-2 


20 


.. 4i „ . 


8 


... 21 


99-4 


21 


.. 5 ,. 


9 


... 3 „ 


99-4 


22 


... 5 ,. . 


10 


... 3 „ ... 


101 


23 


.. 5i .. . 


11 


... 3i .. ... 


98 


24 


.. 6 ., . 


12 


... 3i .. ... 


98-8 


25 


.. 7f ,. . 


13 


... 8i „ ... 


99 


26 


.. 8 ., . 



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246 TBMPBRATUEE IN BELATIOK TO THE DURATION OF LABOUB. 

Or, 26 cases with a second stage averaging 3i hours 
had an average temperature after delivery of 98*8°. 

In 2 cases of craniotomy, performed under chloroform, 
the temperatures were 98*2° and 99°, the second stage 
having lasted 1 hour 10 minutes, and 4 hours respectively. 

In 4 cases of version under chloroform for contracted 
pelvis, the second stage having lasted 1 to 1^ hours, the 
temperatures were 97-4^ 97-6°, 98-8°, 99-8°— an average 
of 98-4°. 

On the other hand, after an intra-uterine douche the 
temperature was almost always raised. I have notes of 
12 cases in which delivery took place naturally, but an 
intra-uterine douche was required, either after the birth 
of a macerated foetus or after exploration for adherent 
placenta or membranes. They are as follows : 

Indication for iDtra-nterine douche. 
Adherent placenta. 

n 

Retained chorion. 
Adherent placenta. 



No. 


Duration, 2nd stage. 


Temp. 


1 


15 min. 


99-4= 


2 


... 15 


it 


98-6 


8 


... 15 


f» ••• 


99-4 


4 


... 15 


f» ... 


100 


5 


... 20 


♦f .•» 


99*8 


6 


... 20 


If ••• 


100-2 


7 


... 20 


3» ••• 


99-4 


8 


... 40 


it ••• 


99-2 


9 


... 45 


it ••» 


97 


10 


... 65 


ft ... 


100-4 


11 


li hours ... 


99-2 


12 


... u 


1> ... 


100 



Macerated foetus. 
Retained chorion. 

. Macerated foetus; adherent placenta. 
Macerated foetus. 
Adherent placenta. 

Thus these 12 cases, with a second stage averaging 
85 minutes in duration, had an average temperature after 
the intra-uterine douche of 99*4^. 

For convenient comparison of the influence upon tem- 
perature of (a) the duration of a natural second stage; 
(6) the duration of the second stage, under chloroform ; 
and (c) the duration of the first stage, Chart III has been 
constructed. The curve a a is obtained from Tables II 
and III, the curve c c from Table I, and the curve b b 



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TSMFEBATITBE IN BILATION TO THB DUBATIOK OF LABOUR. 247 



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S 

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III 

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.IIS 

III 

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^55 



rr 

► ► » 

08 08 08 



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248 TSMPEBATUBE IN BBLATIOK TO THE DUBATIOH OF LABOUft. 

from the above given series of temperatures with chloro- 
form, whether or not forceps were also used. 

The facts before us confirm the general opinion that in 
the first stage of labour, with unruptured membranes, 
delay causes no bad symptoms except such as may result 
from the tedious pain ; whilst in the second stage, delay 
causes rise of temperature and all its associated sym- 
ptoms. 

The infiuence of chloroform is striking, and its action, 
so far as the temperature is concerned, is beneficial. It 
probably operates in two ways : firstly, by quieting emo- 
tional disturbance ; secondly, by suspending, wholly or in 
part, the action of the voluntary muscles associated with 
parturition. 

The rise of temperature after the intra-uterine douche 
is to be attributed, partly to the mental disquietude of the 
patient which is caused when no anaesthetic has been used 
and the utorus has been explored, and partly, in all pro- 
bability, to the direct transmission of heat to internal 
parts. 

Dr. CuLLiNowoBTH Said that Dr. Giles's paper, though ex- 
tremely valuable and interesting, was not one that lent itself to 
discussion. He would like, however, to suggest that the title 
should be slightly altered. The paper dealt with the lying-in 
woman's temperature, not only m relation to the duration of 
labour, but to other conditions. He would therefore suggest 
that the words " duration of labour" should read '' duration and 
other characters of labour." He was glad to notice that the use 
of chloroform had not been found to exercise anj prejudicial 
influence upon the post-partum tem|>erature. It had already 
been cleared from the imputation of increasing the liability to 
post-partum heBmorrhage, and now it had successfully passed 
through another ordeal. 

The Pbbsidbnt said that in this carefully written paper, 
which must have iuToWed much labour, Dr. Giles had broKen 
new ground. Abundance of observations were on record 
showing the conditions on which the grave febrile illnesses 
of the puerperal state denended. This paper was the first 
attempt he xnew of to reauce to law the minor temperature 
variations of normal lying-in. These variations, although they 
might be in the present state of knowledge unimportant, 



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T£MPBBATUBE IN RELATION TO THE DURATION OF LABOOR. 249 

because not leading to inferences useful in the management of the 
case, jet could not be fortuitous ; and work such as Dr. GiWs» 
showing us the causes on which such variations depend, could 
not fail to be ultimately of practical use. As no one that he knew 
of had made any similar investigation, thej were hardly able 
at present to criticise Dr. Giles's work. 



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ON THE CHANGE IN SIZE OF THK CERVICAL CANAL. 251 

blocks it up. Others have said that the canal dilates 
during menstruation. Most assertions either way are 
based on theory, not on observation. The only author 
that I can find whose statement is more than an opinion 
is Dr. Burton, of Liverpool.* He passed the sound in six 
subjects while they were menstruating. He found that it 
went in easily, and he thought that it passed more easily 
than in most women who were not menstruating. Dr. 
Burton's observations at least show that the cervical 
canal was in his cases not appreciably smaller than in 
women not menstruating. The correctness of Dr. Burton's 
opinion that it was larger depends upon the delicacy and 
trustworthiness of his muscular sense of the resistance 
overcome, and his discrimination of the cause of that 
resistance. 

I have tried to find out by a more definite method 
whether the size of the canal alters, and how much it 
alters. The method I have adopted is that of passing 
bougies into the cervical canal, beginning by trying to 
pass a larger one than I expected the canal would admit, 
and then using smaller and smaller ones, until a size was 
reached which would pass the canal. 

Information as to the size of the cervical canal cannot 
be got by beginning with a small bougie and then passing 
larger and larger ones, because the passage of each bougie 
dilates the canal, and therefore the result of this pro- 
ceeding only shows the dilatability of the canal, and not 
its size. I found that even passing the one bougie which 
gave information as to the size of the cervical canal 
dilated it so that on the following day a larger bougie 
could be passed ; and this reason alone made it impossible 
to watch the change in size of the cervical canal from day 
to day in the same patient. 

I submit conclusions based on observations in thirty- four 

women. In each case the canal was measured in the way 

described, while the patient was menstruating, and also at 

a time when she was not menstruating ; in thirty cases 

• ' BritUh MecUcal Journal/ 1884, vol. ii, p. 607. 



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252 



ON THE CHANGE IN SIZE OF THE 



before the menstraation daring wUch the canal was mea« 
sured, in four cases after it, in eight both before and 
after. Most of the observations I made myself, but some 
were made for me by gentlemen acting at the time as 
Resident Accoucheur in the London Hospital. The 
observations on each patient were, with two exceptions, 
always made by the same observer, lest the difference in 
the amount of force used by different persons in passing 
the bougie should make the result incorrect. The names 
of the gentlemen to whom I am indebted for this assist- 
ance are shown in the table ; they are Mr. Walter 
Blaxland, F.R.C.S.Eng., now of Sydney, New South 
Wales ; Mr. Percy Vaughan Jackson, now surgeon in Her 
Majesty^s Navy; Mr. G. C. W. Wright, now Assistant 
Surgeon, General Post Office ; Dr. H. G. Lys, M.D.Lond., 
now of Bournemouth; and Mr. Wm. Penberthy, now 
Assistant Medical Officer, Borough Asylum, Mapperly Hill, 
Nottingham. 

Of the thirty-four patients, eleven had had children, one 
had had an abortion, twenty-two had never been pregnant. 

The size of the cervical canal when the patient was not 
menstruating is shown in the following table. In those 
measured both before and after menstruation, the measure- 
ment before menstruation was in the cases in which the two 
differed, the smaller of the two, and is the one taken in the 
table. 



K of bongie. 


Total paUenti. 




Never pregnant. 


6 


1 


— 


1 


6 


2 


— 


2 


7 


6 


4 


2 


8 


10 


8 


7 


9 


6 


1 


5 


10 


5 


4 


1 


11 


8 


— 


3 


12 


1 


1 


— 



It will be seen that bougies 7, 8, and 9 represent the 
usual size of the canal ; and that in this, parity does not seem 
to make much difference. 




CBBVICAL CANAL DT7BIN0 MBH8TBT7ATION. 253 

In some cases the cervical canal was measnred twice 
daring a menstruation. The interval between the 
measurements was either two or three days. 

I now summarise the measurements during menstruation 
as compared with those taken before its commencement 
or after its cessation. 

In 13 cases the cervical canal was measured on the 
first day of menstruation. In 2 its size was unchanged i 
in 11 it was larger. Of the 11^ in 4 a bougie one size 
larger passed ; in 6 a bougie two sizes larger passed ; in 
1 a bougie three sizes larger passed. 

In 12 the cervical canal was measured on the second 
day of menstruation. In 1 its size was unchanged ; in 11 
it was larger. Of the 11, in 3 a bougie one size larger 
passed; in 5 a bougie two sizes larger passed; in 1 a 
bougie three sizes larger passed ; in 1 a bougie four sizes 
larger passed ; in 1 a bougie five sizes larger passed. 

In 12 the cervical canal was measured on the third day 
of menstruation. In all it was enlarged.' In 2 a bougie 
one size larger passed; in 8 a bougie two sizes larger 
passed ; in 2 a bougie three sizes larger passed. 

In 6 the cervical canal was measured on the fourth 
day of menstruation. In 1 its size was unaltered ; in 5 
it was enlarged. In 2 a bougie one size larger passed ; 
in 1 a bougie two sizes larger passed ; in 2 a bougie three 
sizes larger passed. 

In 8 the cervical canal was measured on the fifth day 
of menstruation. In all it was enlarged. In 4 a bougie 
one size larger passed ; in 4 a bougie two sizes larger 



In 5 the cervical canal was measured on the sixth day 
of menstruation. In 1 its size was unchanged; in 4 a 
bougie one size larger passed. 

The broad result of this investigation is, that in every 
case the cervical canal was larger during menstruatioD 
than in the interval ; in other words, that it spontaneously 
dilated. The dilatation seems to have been greatest on 
the third and fourth days of menstruation,^ but the 

VOL. XXXVI. 18 



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254 ON THS CHANOB IN 8IZS OF THE 

nnmber of observations is too small to enable me to assert 
that this is the rule. 

Some measurements made during the intermenstrual 
period showed that sometimes the cervix dilates although 
the patient is not menstruating. In one case (No. 26) 
eleven days before menstruation No. 11 bougie could be 
passed^ but it subsequently contracted so that only No. 6 
would pass. In another case (No. 1 1) the cervical canal 
was found enlarged two weeks before menstruation, and 
subsequently became swollen again. In two cases 
(Nos. 4 and 9) the cervical canal had been dilated more 
than a month previously for dysmenorrhoea ; and the large 
size of the canal in these cases goes to show that the 
mechanical effect of dilatation in enlarging the canal does 
not quickly pass off. 

It would be interesting and instructive to know the 
causes upon which variations in the size of the cervical 
canal of the unimpregnated uterus depend ; but the eluci- 
dation of this question would need an enormous number of 
manipulations not beneficial but very disagreeable to the 
patients, so that such an extension of this investigation 
seems to me impracticable. 

The mechanical theories that have been so widely 
accepted as to the nature of dysmenorrhoea suggest the 
question, — Does the amount of menstrual pain bear any 
relation to the size of the cervical canal f 

Eighteen menstruations were observed during which 
the patients complained of much pain. 

The maximum size observed during these menstruations 
was the following : — ^No. 7 bougie in one case ; No. 8, 
one case ; No. 9, two cases ; No. 10, seven cases ; No. 11, 
four cases ; No. 12, two cases ; No. 18, one case. 

Fourteen of the menstruations observed were painless. 
The maximum size of the cervical canal observed in these 
cases waff the following : — No. 7 bougie in one case ; 
No. 8, one case; No. 10, four cases; No. 11, one case; 
No. 12, two cases ; No. 1(5, two cases ; No. 14, two cases ; 
No. 15, one case. 



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CBBVICAl CANAL DUBINO MBNSTEUATION. 255 

It will be seen that althoagh in some of those who' 
menstruated withont pain the cervical canal was larger 
than in any of those whose menstruation was accompanied 
with pain^ yet there is no such great difference between 
the size of the canal in the two sets of cases as should 
be the case if the mechanical theory of dysmenorrhoea 
were the correct explanation of a large proportion of cases. 

One more question suggests itself. Is the size of the 
canal in relation to the quantity of the flow ? 

Some of the patients said the flow was moderate in 
amount, others copious, others scanty. Taking the ex- 
treme cases, I find eight in which the flow was said to be 
copious. In these the maximum size of the cervical canal 
was the following : — No. 8 bougie in one case ; No 10, 
two cases ; No. 11, two cases; No. 12, one case ; No. 13, 
one case; No. 15, one case. 

In eleven the flow was said to be scanty. In these the 
maximum size of the cervical canal was No. 8 bougie in 
two cases ; No. 10, five cases ; No. 11, two cases; No. 12, 
one case ; No. 13, one case. 

It is clear from these figures that the difference be- 
tween the size of the cervical canal in those who men- 
struated copiously and those who menstruated scantily is 
not so marked as it would be if the expansion were simply 
proportionate to the amount of the flow 

Summary. — The measurements detailed in this paper 
show — 

1. That spontaneous dilatation of the cervical canal, 
slight in degree, takes place during menstruation. 

2. That this dilatation is at its maximum on the third 
and fourth days of menstruation. 

3. That this dilatation takes place in those who men- 
struate with pain as well as in those who menstruate 
without pain, and in those who menstruate scantily as well 
as in those who menstruate copiously. The measurements 
show no marked concomitant variation between the 
amount of dilatation and the amount of the pain or the 
amount of the flow. 



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256 



OM THB CHANOI IN SIZB OF THB 



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CERVICAL CANAL DURIKG MENSTRUATION. 257 



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258 ON THE CHANGE IN SIZE OF THE 

Dr. CuLLiNawoBTH said tbat the President's paper, like that 
of Dr. Giles, was not of a kind to invite prolonged discussion. 
He was glad that this question had been investigated, and tbat 
some definite information on the subject had been obtained. 
One statement in the paper he had listened to with some 
surprise, viz. that the effects of artificial dilatation of the 
cervix were sufficiently lasting to vitiate any observations made 
on the following daj. He would like to ask Dr. Herman upon 
how many observations this statement was based. The current 
impression was, he thought, tbat the effects of artificial dilata- 
tion of the unimpregnated uterus passed off much more quickly 
than this statement would seem to imply. 

Dr. Abthitb Giles asked whether the observations referred 
to the cervical canal only, or whether the bougies were passed 
through the internal os to the fundus. [The President signified 
that they were passed through the internal os.] The latter 
being the case, it was very suggestive that the maximum 
dilatation was on the third and fourth days. If Mr. Heape*s 
accoant of menstruation in Sem/nopUhecvs enteUue could be 
applied to human menstruation, the period of desquamation 
would correspond to Dr. Herman's period of greatest dilatation. 
The dilatation would then depend, partly at least, on anatomical 
conditions. The early dilatation on the first day was probably 
of a different kind, namely, functional, corresponding in minia- 
ture to the dilatation that occurred in the first stage of labour. 

Dr. C. H. P. RouTH. — After thankii^ Dr. Herman for his 
valuable paper. Dr. Bouth ventured to say that while nothing so 
precise as what Dr. Herman had stated had been noted before, it 
was one of the first lessons that he had been taught in gynsBcoiogy 
that the uterus almost invariably dilated during mendtifuation. 
Advantage was taken of this fact in cases of dysmenorrhcea in 
which the os appeared closed, or was so small as not to admit 
the smallest probe under ordinary circumstances, to wait till a 
period came on, when the small os opened gradually, however 
little, and could be seen and dilated. Again, we were all con- 
versant with those cases in which the dysmenorrhcBa was so severe 
that if the patient was not helped she might writhe for hours 
in agony on the floor, and yet after some time the pain would 
abate, and the courses would flow with great relief of the pains. 
This was doubtless due to some spasmodic action in the uterine 
canal in many cases, sometimes to a flexion which had to be 
overcome, by the m8 a tergoy of the catamenia, retained in the 
upper part of uterus. An anodyne or antispasmodic would 
sometimes relieve the pains at once. All this proved that some 
spasmodic action or a contraction of the canal of a neurotic 
character was often at first present, which had to bo overcome, — 
analogous, he supx)Osed, to what took place in the male urethra 
when a sound or catheter was passed, or during irritation of the 



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CERVICAL CANAL DURINa MENSTRUATION. 259 

canal contracting forcibly on the sound, and being with difficulty 
withdrawn until the spasm had ceased. So we might explain 
the gradual dilatation of the uterine canal up to the second or 
fourth day, although preceded by a contraction. There was 
another probable source of this difficulty. We all knew that, 
like the breasts, the uterus enlarges prior to menstruation. 
It could be easily felt enlarged by a bimanual examina- 
tion, and the same thing also occurred in fibroids. Now the 
uterus was, after all, a closed bag, and it could be understood 
how at first, by local congestion around the internal cavity, its 
tubular canal would be compressed at first and eloi^ted as the 
uterus rose in the pelvis, and so be smaller at first but subse- 
quently assume its normal length and width. Perhaps Dr. 
Herman could, either from his present facts observed or in the 
future, tell the Society whether the length of the uterine camd 
was increased as well as its width. 

The President said that his measurements were of the 
cervical canal ; but the os internum was the narrowest part of 
this. He could draw no distinction between the functional and 
the anatomical os uteri. Menstruation seemed to him like a 
miniature labour ; as the cervix dilated in labour, so it did, but 
in much less degree, in menstruation. Dr. Eouth's observation 
as to a pinhole os uteri admitting a sound during menstruation, 
but not at any other time, was valuable. He had not been able 
to find any publication to this effect. Dr. Eouth's remarks as 
to the swelling of the uterus blocking up the canal, he thought 
illustrated the need for observations such as be had in this 
paper submitted to the Society. 



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OCTOBER 3ed, 1894. 

G. Ernest Herman^ M.B.^ President^ in the Chair. 

Present — 50 Fellows and 5 visitors. 

Boland Danvers Brinton, B.A.^ M.D.Cantab. ; Reginald 
T. H. BodiUy, L.R.C.P.Lond. ; and W. 0. Loos, L.R.O.P. 
Lond., were admitted Fellows of the Society. 

Robert Kingdon Ellis, M.B., B.Ch.Oxon., was elected 
a Fellow of the Society. 

The following gentlemen were proposed for election :— 
Walter Meent Borcherds, M.R.O.S. (Cape Colony) ; 
Arthur Mantell Daldy, M.D., B.S.Lond.; Thomas Vere 
Nicoll, L.R.C.P.Lond.; Adam William Thorbum Steer, 
M.R.C.S. ; William Atkinson Stott, M.R.C.S.; Allen 
James Swallow, M.B., B.S.Durh. ; John D. Williams, 
M.D.Edin., B.Sc. 



INCOMPLETE TUBAL ABORTION. 
By L. Rbhfbt, M.D. 

Dfi. REMfBT showed a specimen of the above which he 
had removed from a woman aged twenty-eight. 

It consisted of (1) the dilated tube, (2) part of the 
right broad ligament, and (3) the right ovary. The tube 
was about the size of a ripe banana, and at the time of 
operation was distended with blood-clot. The fimbriated 

VOL. 2XXVI. 19 



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262 INCOMPLETE TUBAL ABORTION. 

extremity was dilated to the size of a sliillingi and was 
surrounded by fine processes, the remains of the fimbrias. 
An incision had been made into the tube and exhibited 
a rounded mass — the tubal mole. Microscopical exami- 
nation of this had shown chorionic villi. 

The patient was admitted to the Great Northern 
Hospital on May 19th with the history that a fortnight 
before she had had an early miscarriage. (It was subse- 
quently thought that this had been a decidual cast only.) 
She looked pale, and complained of pain in the right iliac 
fossa and lower part of abdomen. The temperature and 
pulse were normal. On examination, Douglas's pouch 
and the lower half of the pelvis were found filled with a 
rounded rather irregular soft resistance, which felt like 
blood-clot, while in the situation of the upper part of the 
right broad ligament was an elongated mass like a large 
sausage. The uterus appeared to be enlia.rged to about 
three times the usual size. The case was diagnosed as 
ruptured tubal gestation. After two or three days the 
pain subsided, the temperature remained normal, and 
the patient felt quite comfortable. Complete rest was 
ordered. 

On June 7, i. e. about five weeks after the supposed 
miscarriage, the temperature rose to 101°, and continued 
at about the same height till June 15th. This appeared to 
indicate decomposition in either the haematocele or in the 
mass in the broad ligament. Fresh pain and tenderness 
in the right iliac fossa suggested some change in the 
latter. 

After consultation Dr. Remfry opened the abdomen, 
removed the specimen shown, and after breaking down 
the adhesions surrounding the blood-clot thoroughly 
washed out the pelvis. A drainage-tube was left in for 
thirty-six hours. The temperature on the second day 
was 100°, and on the third day sank to normal, at which 
it remained during the convalescence of the patient, who 
made an uninterrupted recovery. 

In answer to Dr. Cullingworth, Dr. Remfry stated that 



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GESTATION IN A BUDIMENTABT HORN. 263 

apparently no decomposition had taken place in the 
hsematocele, but that a few drops of pus were found in 
the blood-clot in the tube. 



GESTATION IN A RUDIMENTARY HORN. 
By L. Rbmfbt^ M.D. 

Dr. Remfbt exhibited a specimen of the above^ together 
with coloured illustrations. It consisted of a thick-walled 
saCj showing at its left upper part in front the cut ends 
of the left round ligament and left Fallopian tube. 
Through an opening made into the tumour posteriorly, 
the facial portions of the skull of a foetus about six 
months old were apparent. Lying transversely across 
the jaw were three small bones believed to be the femur, 
tibia, and fibula. The thickness of the wall of the sac 
at the site of the incision was about three-eighths of an 
inch. 

The patient from whom the specimen was taken was 
aged about thirty, and came to the hospital complaining 
of an abdominal swelling and pelvic pain. The history 
and examination pointed conclusively to the tumour 
being a fibroid of the subperitoneal variety springing 
from the uterus. For this the patient was treated, and 
the tumour, if anything, slightly decreased in size. 
Treatment, however, did not alleviate the symptoms, and 
after some months it was decided to remove this so-called 
fibroid, owing to the extreme pain and discomfort produced 
by it. The operation was straightforward, the pedicle 
being no thicker than that of an ordinary ovarian cyst. 
On passing the hand down into the pelvis, the right portion 
of the uterus with its Fallopian tube and round ligament 
was felt curving towards the right side. 

The patient did very well after the operation, and on 



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264 GT8TIC SARCOMA OF OMENTDH. 

the seventh day the stitches were removed, and the 
wound seemed to be qnite healed. On the eighth day, 
however, she had a violent fit of coughing, and after a 
time it was discovered that some coils of small intestine 
had escaped underneath the dressings. The gut was very 
red and dry. On opening the abdomen all the intestines 
except the escaped portion were perfectly healthy in 
appearance, as also was the stump. The peritoneal 
cavity was washed out with hot water, and all possible 
means were adopted to try and save the patient, but she 
never recovered the shock, and died next day. 

As to the diagnosis. Dr. Remfry said that when there 
had been no history of amenorrhoea, or of any symptoms 
or signs of pregnancy, the nature of the tumour during 
life could not be determined. Such a tumour, as far as 
he could ascertain, had always been diagnosed as a 
fibroid. After operation, when foetal remains were found, 
the question was simply between (a) extra-uterine gesta- 
tion and {b) gestation in a uterine horn. In (a) the 
round ligament and Fallopian tube were on opposite sides 
of the tumour ; in (b) on the same side. 

In answer to Dr. William Duncan, Dr. Remfry said 
that he had not used strapping for the abdomen, and, in 
fact, did not do so as a rule. 



CYSTIC SARCOMA OP OMENTUM SIMULATING 
OVARIAN TUMOUR— REMOVAL— RECOVERY. 

By William Duncan, M.D. 

Dr. Duncan showed this specimen; it was removed 
from a lady aged sixty-two, on July 22nd, 1894. 

The patient consulted Dr. Duncan on account of pain 
and increase in the size of the abdomen for the last six 
months. 



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CYSTIC 8ABC0MA OF OHSNTUM. 265 

She is a multipara^ and had the menopause sixteen 
years previously. The complexion is sallow, and a good 
deal of emaciation has taken place. On examination the 
abdomen was filled by a large irregnlar tumour, partly 
cystic and partly solid. Fer vaginam nothing abnormal 
was detected. 

On opening the abdomen the large cyst presented and 
was tapped^ when about three quarts of dark blood escaped. 
The tumour was intimately adherent to the omentum, 
and on passing the fingers down into the pelvis the 
ovaries were both found healthy, but very much atrophied 
from age. The uterus was also healthy, perfectly smooth 
on the surface but somewhat enlarged. The tumour, 
which had no pelvic adhesions, was now removed by tying 
the omentum across with a good many silk ligatures. 
After removal of the tumour the abdomen was quite free 
from any growth, and it was evident that the tumour 
sprang from the omentum. 

The patient made an uninterrupted recovery, and before 
returning home had gained flesh and felt perfectly well. 

Note (December 12th, 1894). — The patient, now five 
months after operation, continues well. 

Subjoined is the report on the specimen by Dr. 
Yoelcker, Pathologist to the Middlesex Hospital. 



Report oil a tumour removed from the abdomen, July 22n(2, 
1894, by Dr. William Duncnn. 

The portion removed consists of a mass the size of a 
cocoa-nut. To one surface the omentum is adherent, and 
has been partially removed with the tumour. 

The tumour can be divided into two portions, a larger 
cystic portion and a smaller solid lobulated portion. 

The larger portion consists of a cyst six inches in 
diameter, to the outer part of which omentum is adherent 
on one aspect. The outer wall is roughened in parts 



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266 CYSTIC SARCOKA OF OMENTUM. 

where adhesions have been^ and is also thickened by some 
irregular patches of thickening in the cyst wall. In a 
few places the cyst wall is quite thin. 

The omentum can be almost entirely stripped oflE the 
cyst wall. 

The average thickness of the cyst wall is 1'5 mm. 

The nodular thickenings on section are pale and fleshy- 
looking, rather soft, and into them, in places, haemorrhage 
has occurred. 

The inner wall of the cyst is in the main smooth, but 
it also shows some fleshy masses projecting slightly into 
the cavity of the cyst in discrete patches. 

The cyst itself was filled with soft material resembling 
blood-clot, but on microscopic examination it was found to 
be composed of elongated spindle-cells, and of branched 
myxomatous cells, and also large round cells, in addition 
to blood-corpuscles. • 

The more solid portion of the tumour is lobulated-; the 
outer surface is smooth, though the omentum is adherent 
to some of it. Some of the lobulated portions are blood- 
stained, and these are soft. 

On section the largest mass is solid, yellowish white, 
and lobulated. It shows numerous foci of haBmorrhage, 
and in the centre is a yellow granular debris. Teased 
portions of this pale mass show a structure similar to that 
found in the large cyst. 

A portion of the solid growth was hardened in alcohol, 
embedded in celloidin, and sections were prepared. These 
showed the growth to be composed of spindle-cells, oat- 
shaped and oval cells arranged in bundles running in 
different directions. Portions of the growth show mucoid 
softening, and in others are considerable patches of haemor- 
rhage. 

There was no evidence of any glandular structure. 

The blood-vessels in the growth are numerous. 

The growth thus presents the characters of a spindle 
and oval celled sarcoma, into a portion of which haemor- 
rhage has taken place forming a cyst. 



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DERMOID CYST OP BIGHT OVARY. 267 

I am unable to indicate the part in which the growth 
originated ; most probably it was in the omentum. 

Arthur Francis Voelcker. 



DERMOID CYST OP RIGHT OVARY— TWISTED 
PEDICLE. 

By William Duncan, M.D. 

Dr. Duncan showed a large dermoid tumour of the 
right ovary, the pediele of which, at the time of 
operation, was found to be tightly twisted three times 
from right to left; the tube and fimbriated extremity 
were enormously distended with oedema, and the cyst- 
wall had in its upper part become necrosed. 

The patient from whom it was removed was a single 
girl aged twenty-one, who noticed her abdomen getting 
larger for about a year. She consulted Dr. Roberts at 
the Samaritan Hospital, who diagnosed an ovarian tumour. 
The hospital being closed, she was kept under observation, 
but acute symptoms set in with great abdominal pain, and 
Dr. Roberts asked Dr. Duncan to take her into the 
Middlesex Hospital. On admission the abdomen was 
greatly distended and extremely tender, so that no 
definite tumour could be made out. The temperature waa 
102*4°. Abdominal section was performed, and the 
patient made an uninterrupted recovery. 



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268 



LARGE GANGRENOUS INTERSTITIAL MYOMA 
OP THE UTERUS. 

By C. J. CULLINOWORTH, M.D. 

Db. Cullikgwobth exhibited a utems containing several 
interstitial myomata^ removed by abdominal hysterectomy 
from a patient sixty-one years of age. The main tumour 
formed an abdominal swelling of the size^ and somewhat 
of the shape of a pregnant uterus at term. It had been 
growing rapidly since Christmas last, in consequence, the 
patient believed, of a fall she had at that time ; and, on 
section after removal, it was seen to be in a gangrenous 
condition throughout. It emitted an odour like that of 
stale fish, and was of a greyish-yellow colour. In its 
interior was a large irregular cavity with ragged walls, 
containing offensive fluid mixed with necrotic tissue. 
There was a group of smaller tumours, apparently of 
cervical origin, completely filling the pelvis. These did 
not show any evidence of necrotic change. 

The patient had ceased to menstruate at the age of 
fifty. There had been no haemorrhage since. There had 
been diflBiculty in micturition for two years, but no retention. 
Persistent vomiting with rapidly increasing debility had 
been present for three weeks previous to the patient's 
admission. 

The abdominal portion of the tumour with the hyper- 
trophied body of the uterus was first removed, and then the 
pelvic tumours were enucleated. There was very little 
bleeding. The stump was trimmed, and the peritoneal 
flaps united over it by a line of seventeen Lembert's 
sutures of silk. 

The tumours weighed 24^ lbs. 

The patient bore the operation remarkably well, and 
for two days gave promise of a good recovery. At the 



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LARGB GANGRENOUS INTERSTITIAL MYOMA OF THE UTERUS. 269 

end of that time, however, septic symptoms developed, 
and she died on the fifth day. 

At the autopsy three to four ounces of highly oflEensive 
blood were found in the interior of the stump. There 
was evidence of adhesive peritonitis. The descending 
colon was collapsed ; the small intestines were filled with 
fluid faeces. The cervical canal was elongated to a length 
of 4i inches, was of extremely narrow calibre, and was 
sharply curved upon itself. It therefore had entirely 
failed to act in the usual manner — as a drain to the 
interior of the stump. 

Dr. Cullingworth said he regretted not having in this 
case made an incision through the vaginal roof to afford 
an outlet for the blood effused into the interior of the 
stump. There was no tension, however, in that situation, 
or other evidence to show that there was an accumulation 
of blood there, or that the interior of the stump had 
become the seat of septic change. 

The main interest of the case lay (1) in the occurrence 
of gangrene in a tumour which was wholly interstitial, and 
where there had been no possibility of accidental infection 
either from the introduction of a sound or from surgical 
interference of any kind; and (2) in the evidence it 
afforded that uterine myomata did not invariably cease to 
be a source of danger to life even long after the meno- 
pause. 

The patient had been under the care of Dr. Culling- 
worth's predecessor. Dr. Gervis, in the year 1875, when 
the tumour is stated to have been the size of a cocoa-nut. 
It had therefore been known to exist for nearly twenty 
years. 

Dr. Hayes certainly thought that intra-peritoneal treatment 
of the cervical stump would, sooner or later, become generally 
recognised as appropriate in hysterectomy for fibroid tumours. 
Some time ago he himself had brought forward in this Society 
a most successful case of this method, which at the moment 
was received with severe criticism. He was glad to find that 
Dr. Cullingworth now adopted it. He, however, in one parti- 
cular strongly differed from Dr. Cullingworth. He thought 



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270 FIBBO-CTSTIC TUMOUE OF THE UTERUS. 

the peritoneal end of the stump shonld have the cervical open- 
ing closed, and as oompletelj as possible. This was best done 
by dissecting out a portion round the opening, then closing it 
with catgut or fine silk sutures, and, if possible, stitching over 
the extremity a portion of the peritoneum. The vagina should 
be purified and stuffed with antiseptic gauze. He considered 
the drainage of the stump objectionable and dangerous. 

Dr. Hetwood Smith remarked on Dr. Hayes' observation 
that drainage through the cervical stump in subperitoneal hyste- 
rectomy was novel to him. In the cases related by Dr. Goffe, 
of New York, as well as those reported by him (Dr. Smith), the 
cervical canal proved a most useful and natural vent for the 
evacuation of purulent discharge that not unfrequently took 
place, in consequence, probably, of the pressure of the silk liga- 
tures, and in some instances the li^tures were thrown off 
through the os uteri. 

Dr. CuLLiNGWoBTH, in reply to the President, said that the 
tumours, so far as could be ascertained, were of the hard 
variety. He could not say whether there had been continuous 
growth ever since the menopause, but there had certainly been 
rapid increase in size during the present year. In answer to 
Dr. Lewers he stated that he had not drained the peritoneal 
cavity, as there had been no indication for so doing. He 
regarded a patulous cervical canal as a valuable outlet for any 
blood that might otherwise accumulate from oozing in the 
interior of the closed stump. He had now abandoned the 
extra-peritoneal treatment of the stump as a routine method, 
resorting it for exceptional cases only. The insignificance of 
the hsemorrhage during the operation was due to the uterine 
arteries having been tied as a preliminary. 



FIBEO-CYSTIC TUMOUR OP THE UTERUS RE- 
MOVED BY ABDOMINAL SECTION. 

By Aethur H. N. Lewers, M.D. 

Dr. Lkwbrs showed this specimen. The history of the 
case was as follows. 

Miss S — , aged 45, was brought to see Dr. Lewers by 
Dr. Warren, of Enfield Highway, in December, 1893. 
The abdomen had been noticed to be enlarging for about 



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FIBEO-CYSTIC TUMOUR OP THE UTEEUB. 271 

three years. Till two years ago patient had been regular 
every four weeks, and always lost very little. For the 
last two years she had not been regular. Latterly she 
had menstruated every fortnight, but the quantity lost 
each time had been very small. On examination there 
was found a thin-walled fluctuating swelling, reaching 
well above the umbilicus and rising out of the pelvis. 
The sound only passed two and a half inches. Dr. Lewers 
diagnosed the case as one of ovarian tumour. At the 
operation, however, after tapping and emptying the cyst 
(which was unilocular and contained a thin straw-coloured 
fluid) he found that both ovaries were normal, and that 
the tumour was uterine. The operation was undertaken 
at the patient's own house at Enfield Highway; fortu- 
nately Dr. Lewers had the serre-noeud and transfixion 
pins with him, and accordingly performed a supra- vaginal 
hysterectomy, fixing the pedicle externally in the lower 
angle of the wound. The pedicle so fixed was, of course, 
composed of uterine tissue, but Dr. Lewers did not see 
the cavity of the uterus at all, and believes that it was 
not opened. The parts removed were the cystic tumour 
and a portion of the fundus of the uterus. The ovaries 
were so situated that there was no need to interfere with 
them. The patient made an absolutely uneventful re- 
covery, and there is no sinus at the lower angle of the 
wound, which is soundly healed throughout. The patient 
has been regular since the operation. 

Dr. Lewers spoke of the diflSculty of the diagnosis 
between an ovarian and a large thin-walled, fibro-cystic 
tumour of the uterus, such as that in this case. The 
only absolutely distinctive physical sign was to retrovert 
the uterus strongly with the sound, and to get the finger 
per rectum above the fundus uteri. Still this distinction 
failed when an ovarian tumour was adherent to the 
uterus, as occurred not very rarely. It appeared, there- 
fore, that an absolute diagnosis must be sometimes im- 
possible till the abdomen was opened. Another point in 
connection with this subject appeared to him of import- 



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272 TWO CASES OF PSEUDO-HEBMAFHRODITISM. 

ance. To all appearance this case was a perfectly simple 
one of ovarian tumour, promising that the operation 
would be an easy one and without complication. The 
event proved it to be far otherwise, and illustrated once 
more that no one was justified in undertaking ovariotomy 
who was not prepared to deal with unexpected com- 
plications. 



TWO CASES OP PSEUDO-HERMAPHEODITISM. 

By J. H. Targett, F.R.C.S. 

(With Plates I, II, III.) 

Case 1. — The following notes, with the accompanying 
photographs, of a case of supposed hermaphroditism were 
presented to the College of Surgeons by Mr. Grambier 
Bolton, F.Z.S., who saw and examined the individual 
when travelling in the United States. The notes were 
taken by Mr. Bolton. Being written by a layman, a few 
alterations and the substitution of more scientific terms 
were necessary, but with such exceptions the notes were 
entirely those of Mr. Bolton. 

Pauline S — , aged 26 years, bom at Lennox, Mass., 
on May 18th, 1867. The father is American, the mother 
English ; both normal. Their family consists of five chil- 
dren, three boys and two girls. All the children but this 
one are normal, are married, and have families. 

General appearance. — Height five feet nine inches, hair 
light brown, complexion rather sallow, eyes brownish grey. 
The individual would pass as a strong, well-formed young 
woman. Voice rather masculine, but neither gruff nor 
high-pitched like that of a eunuch. Until nineteen years 
of age P. had an alto singing voice, but this was lost in 
consequence of a severe cold contracted at sea. 

Physical examination, — Body well developed and well 
nourished. Arms and thighs like those of a finely grown 



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TWO CASES OP PSBUDO-HEBMAPHHODITISM. 278 

woman. Shoulders sloping, hips large and roomy, has a 
decided waist, and wears 20-inch corsets. Hands 
rather large, with strong fingers and well-shaped nails. 
Breasts and nipples small for her age, about the normal 
size of those of a girl at fifteen. During menstruation 
there are distinct sensations in the breasts at times, but 
with no sign of secretion. 

The hair on the head is soft and fine in quality, and 
reaches nearly to the waist. In the axilla and upon the 
mons Veneris it is somewhat lighter in colour than that of 
the head. No sign of hair upon the face, arms, or legs, 
or around the nipples. The supra-pubic hair has the 
female outline, and does not extend up towards the um- 
bilicus. The skin of the upper lip, chin, and cheeks is 
quite soft and smooth. 

Genital organs. — The external organs apparently con- 
sist of a penis, scrotum, testes, and vulva. The penile 
organ is situated about two inches in front of the vulval 
opening; it is described as well and perfectly shaped, 
except that it is imperforate. It measures rather less 
than three inches in length when relaxed, but in a state 
of erection it is about five inches long. During erection 
the organ is bent downwards by a strong fraenum beneath 
the glans (Plate I). 

The so-called scrotum consists of two separate pouches, 
one on either side of the penile organ. The testes are 
described as being " set very high up and wide apart /^ 
they are small, and each is contained in the corresponding 
scrotal pouch. 

The vulval opening is placed just behind the penile 
organ and scrotal pouches. No mention is made of labia, 
but the accompanying photograph shows small folds of 
integument occupying the position of labia majora, and a 
wide interval corresponding with the perineal space. 
The orifice of the vagina is stated to be smaller than 
normal, and from the appearance of the parts it would 
seem to be impossible for copulation to take place with 
an average sized man. It is further stated that the 



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274 TWO CASES OF PSEUDO-HEBICAFHRODITISM. 

uterus, ovaries, and urethra have been recognised by 
careful examination at different medical colleges in 
America, — ^for example, the hospital at Albany in New 
York State. 

Sexual history, — Pauline S — always dresses as a 
woman, — in fact, could not wear men's clothes on account 
of a menstrual discharge and the mode of passing urine. 
In riding on horseback always sits as a woman, and has 
performed as a female bare-back rider in circuses. On 
the other hand, the sexual inclinations are entirely towards 
women. P. lives with a young woman aged twenty-three, 
and they appear to be very fond of each other, and say 
that they derive great pleasure from sexual intercourse 
with each other. During copulation P. is conscious of an 
orgasm, and an emission occurs from the vulval opening 
which is composed of mucus, and shows no signs of 
spermatozoa. Menstruation takes place with considerable 
regularity from the vagina, and urine is passed in the 
normal female manner. 

With regard to the sexual instincts, it should be added 
that P. has never tried to have intercourse with a man, 
because the opinion has been expressed that if pregnancy 
occurred it would be necessary to remove the child by an 
operation, which might prove fatal. Though not gaining 
a livelihood by exhibiting the deformity, P. was anything 
but shy and reserved; the character was decidedly 
masculine. 

BemarJcs. — The female characters of this individual 
undoubtedly predominate, e. g. the shape of trunk and 
extremities, the sloping shoulders and decided waist, the 
distribution and character of hair, the occurrence of 
menstruation, the presence of vulva and vagina, and per- 
haps uterus. The male features are confined to the voice 
and sexual instincts, for the supposed testes might well be 
herniated ovaries, and the absence of spermatozoa supports 
this. Thus the condition is reduced to one of marked 
hypertrophy of the clitoris and hernia of the ovaries in 
association with altered sexual inclinations. 



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" "^s^.. 



Plate 



X 



We3t.Ncwmaji lith. 
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Plate II 



We^t.Ne-wTiiJiTi lith. 



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■ Plate III. 




K 



\ 



\t 



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TWO CASES OP P8EUD0-HBBMAPHR0DITISM. 275 

Case 2. — ^The clinical notes and photographs of the 
following case were presented to the College of Surgeons 
by Mr. Davies-CoUey, who has kindly allowed me to 
publish them with the preceding (Plates II and III) . 

Frederick , aged 17 years, a confectioner, came 

under observation in order that some operation might be 
performed upon his genital organs, which would relieve 
him from the necessity of passing his water through an 
opening in his perineum. When born he was thought to 
be a girl, and named Isabel. At the age of seven years he 
was examined by a medical man, and declared to be of the 
male sex. Prom that time he was given a masculine 
name, and was brought up as a boy. Of late he has 
been employed as a man with other men. 

General appearance. — The patient is of low stature, 
. about five feet high, and very muscular. The moustache is 
rather more developed than is usual with lads of his age. 
The mammary glands are those of a man. The genital 
organs were carefully examined, and presented the follow- 
ing characters : — The penis is about 2 inches in length, 
with a glans of the usual masculine form, and about an 
inch in transverse diameter. The organ is as free of the 
surrounding parts as usual in the male ; during erections 
it becomes concave downwards. Though the notch for the 
meatus is well marked there is no urethral aperture, but 
a distinct groove extends along the under surface of the 
organ, and terminates in an opening situated 8^ inches 
from the tip of glans, and IJ inches in front of anus. 
There is no scrotum, but on either side of the penis there 
is a fulness resembling a labium majus, in which, on the 
right side, a moderately firm, tender, and moveable body 
about three-eighths of an inch in diameter may be felt. 
Occasionally a similar mass is present on the left side. 
There is nothing like a spermatic cord. The aperture 
situated at the bottom of the above-mentioned furrow is 
moistened with mucus, and when its edges are held apart 
two openings are seen. The posterior one permits the pas- 
sage of a female catheter for 4j^ to 5 inches. With the 



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276 TWO CASES OF PSEUDO-HEBMAPHBODITISM. 

finger in the rectum this catheter can be felt to be separated 
by a partition of uniform thickness, about one-eighth of an 
inch. There is no prostate to be felt, but a small knot 
or thickening seems to terminate the passage. On with- 
drawal of the catheter a little blood and mucus appeared, 
but no urine ; when the catheter was introduced into the 
anterior opening some clear urine flowed. The last joint of 
the little finger can be inserted into the posterior passage 
without much difficulty, but causes pain. The entrance 
to the passage seems somewhat constricted by a membrane 
like the hymen. There has never been any discharge of 
blood as in menstruation, and the mother, who has several 
other children, says that the patient has always been like 
a boy in character and habits. 

Bemarhs. — ^After careful examination the conclusion 
was arrived at, that while the general appearance and 
disposition of the patient were those of a male, his genital 
organs were those of an immature female, with the ex- 
ception of the clitoris, which resembled the organ of a 
hypospadiac male. The right labial swelling was pro- 
bably a hernia of the ovary. The patient was recom- 
mended to retain male attire and occupation unless any 
sign of menstruation appeared. 



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277 



THREE CASES OP PELVIC INFLAMMATION 
ATTENDED WITH ABSCESS OP THE OVARY, 
WITH CLINICAL REMARKS. 

By Charles J. Cdllingwobth, M.D., P.R.C.P., D.C.L., 

OBSTBTSIC PHTBICIAK TO ST. THOMAS'S HOSPITAL. 

(Received June 2Ut, 1894.) 
(AbstrcLcL) 

Thb author points out that the form of pelvic inflamma- 
tion with which small suppurating cysts of the ovary and 
ovarian abscesses are usually associated is not pelvic cellulitis, 
but salpingitis, the ovarian suppuration being due to secondary 
infection. He briefly describes the course of events when sal- 
pingitis is attended with profuse suppuration, showing how the 
pus may either be confined in the Pallopian tube (by occlusion 
of the abdominal ostium), or (if the abdominal opening remain 
patulous) be discharged through that opening and form an 
intra-peritoneal abscess. He points out that although the 
usual seat of such an intra-peritoneal abscess is the pouch of 
Douglas, it may, in cases where the tube has been lifted out of 
the pelvis by the development of the pregnant uterus, form in 
a different situation, — ^f or example, at the upper and lateral part 
of the pelvis, near the brim. He shows that wherever the 
intra-peritoneal abscess is formed it is usual to find the ovary 
constituting part of its wall. In this way the ovary is specially 
liable to secondary infection, the more so, probably, if it is 
already the seat of incipient cystic disease. 

Three cases are related of abscess in the ovary due to secon- 
dary infection of this kind. In the first case two separate 
abscesses were found in the ovary, one at its outer end close to 

VOL. XXXVI. 20 



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278 PELVIC INFLAMMATION ATTENDED WITH 

the intra-peritoneal abscess, and one at its inner end some 
distance away. In the second case there were also two ab- 
scesses, but the mischief was more advanced, a communication 
having been opened up between the two abscesses by a process 
of ulceration. In the third case a still more advanced stage 
was seen, the ovary having ruptured and the contents of the 
abscess having escaped. The first two were puerperal cases, and 
in them the intra-peritoneal abscess, formed by the discharge of 
the contents of a suppurating Fallopian tube, was situated high 
up in the pelvis, close to the edge of the psoas muscle where it 
overhangs the pelvic brim. In each case the suppui*ating ovary 
formed part of the wall of the abscess. These two cases re- 
covered, the third died. 

The narration of the cases is followed by a few remarks on 
some of the modes of termination of ovarian abscess, and on the 
illusory character of a temporary subsidence of symptoms, with 
apparent restoration to health, in some of these cases of severe 
pelvic inflammation. 

The paper concludes with a reference to eighty-three cases in 
which the author had performed abdominal section for non- 
cellulitic pelvic suppuration. An analysis of these cases shows 
that ovarian suppuration occurred in a large percentage, and 
that, next to purulent salpingitis, it is the most frequent form 
of non-cellulitic suppuration occurring within the female pelvis. 

The following cases^ all three of which happened to be 
under observation at the same time^ and were operated 
upon within a few days of one another^ illustrate in an 
unusually interesting manner some of the more remote, but 
at the same time the most serious dangers incurred in severe 
pelvic inflammation. The form of pelvic inflammation in 
which these risks are encountered is not that which pri- 
marily affects the pelvic connective tissue, but the more 
common form in which, starting from the endometrium, 
the inflammation spreads to the lining membrane of the 
Fallopian tubes, and through them reaches the pelvio 
peritoneum. If the inflammation is of a severe type, and 
is attended with profuse suppuration, one of several things 
may happen. The abdominal ostium of the Fallopian 



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JlfiSCESS OF THE OVABT, 279 

tube may become quickly sealed up by the inflammatory 
process, and the pus may thus be confined within the 
closed tube, forming a pyosalpinx. If, on the other hand, 
the abdominal end of the tube remains open, the pus is 
discharged into the peritoneal cavity. In some cases the 
result is general suppurative peritonitis, but much more 
usually the pus finds itself limited by already formed 
peritonitic adhesions, and the result is an intra-peritoneal 
pelvic abscess. The locality of such an abscess depends 
on the position that the open end of the Fallopian tube 
happened to occupy at the time the discharge took place. 
When the outer end of the tube is lying in its usual posi- 
tion behind the broad ligament, with its mouth directed 
downwards, the abscess forms in the pouch of Douglas. 
But where the occurrence takes place at a time when the 
direction of the tube is other than the usual one — when, 
for example, the tube has been lifted above the plane of 
the pelvic brim during the development of the pregnant 
uterus, and is seized whilst in that elevated position by 
an attack of suppurative inflammation, — the abscess formed 
by the discharge of pus through its fimbriated end may 
be, and often is, situated not in Douglas's pouch, but near 
the lateral and posterior part of the pelvic brim, close to 
the edge of the psoas muscle. This is what happened in 
the first two of the cases here recorded, in both of which 
the original mischief followed parturition, and was septic 
in its character. In the third case, where the source of 
infection was probably an attack of gonorrhcea, the state 
of the parts at the time of the operation made it impos- 
sible to say whether such an abscess as now described had 
existed. If it had, it is certain that it was in Douglas's 
pouch, and not at the pelvic brim. 

When the Fallopian tube has thus got rid of its purulent 
contents, the inflammation of its lining membrane gradu- 
ally subsides, and when it comes to be examined at a 
later stage the inner surface of the thickened and elon- 
gated tube may show nothing more than a general soften- 
ing and oedema. In the meantime the intra-peritoneal 



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280 PELVIC 'INFLAMMATION ATTENDED WITH 

abscess^ closed in amongst adhesions^ may remain for some 
time latent, — that is, it may produce few or no symptoms 
of presence. Sooner or later, however, its walls undergo 
ulceration, and its contents make their escape either into 
the bowel, or the vagina, or the peritoneal cavity, or the 
bladder, with results varying accordingly. 

Meanwhile the infection may spread to contiguous 
parts, and especially to the ovary, which is almost inva- 
riably involved amongst the tissues and organs matted 
together by the peritonitis surrounding the purulent col- 
lection, whether that be in the tube or outside it. The 
three cases here recorded are examples of this secondary 
infection of the ovary. In all of them the ovary had 
become the seat of suppuration; In Case 1, two separate 
abscesses were found in the ovary, one at the outer end, 
close to the intra-peritoneal abscess, and one at the inner 
end, some distance away. In Case 2 there were also two 
abscesses, but in this instance the mischief had advanced 
further, and a communication had been opened up between 
the two ovarian abscesses by a process of ulceration. In 
Case 3 a still more advanced stage was seen, for here the 
ovary had ruptured, and the contents of the abscess had 
escaped. 

Case 1. — A lady aged 35, the wife of an engineer 
residing in India, was admitted into St. Thomases Home 
under my care, January 24th, 1894. She had been 
married eighteen months. Before marriage she had suf- 
fered for some time from pain in the right groin, thought 
to be due to a strain from lifting a chest of drawers. 
She had never had malarial or jungle fever. She was 
attended in her first and only confinement, which took 
place in India on August 12th, 1893, by a nurse-midwife, 
who took no special precautions as to cleanliness, and is 
not remembered to have been seen even to wash her hands. 
The doctor took no part in the delivery, and neither then 
nor subsequently made a single vaginal examination. 
The labour was normal. Two or three days afterwards 



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ABSCE8S OF THB OVABT. 281 

a rigor occurred, accompanied with a rise of temperature 
but with no pain. A second rigor occurred about two 
weeks later, and the patient was in bed a month with 
symptoms of fever. During the latter part of this time 
there were some pain and slight swelling in the left groin. 
The temperature did not become normal until the seventy- 
ninth day (beginning of twelfth week). It remained 
normal until the ninety-fifth day (middle of fourteenth 
week), when it again rose. She now had pleurisy 
ending in empyema, which was tapped and drained. On 
the 111th and 112th days (end of sixteenth week) she 
had a temperature of 105^, preceded by shivering and 
accompanied with vomiting, and what was called bilious 
fever. After this she remained in India another three 
weeks, and on December 27th, 1893, she embarked for 
England. Whilst on board ship she had pain and swell- 
ing in the right iliac region with pyrexia, and for three 
days before reaching Naples the pain had been so severe 
that she landed at Naples with a view to taking medical 
advice as to the propriety of continuing her journey. Dr. 
Gairdner advised her to do so. She followed his advice, 
and on reaching England was admitted into St. Thomas's 
Home. 

The note made on her admission describes her as a 
.light-complexioned woman, pale and emaciated, but of 
bright and cheerful disposition. She complained of little 
pain. Her temperature was normal in the morning, and 
about 100° in the evening. There was a solid swelling the 
size of a closed fist, smooth, hard, and fixed, extending up- 
wards for a height of 2^ inches above Poupart's ligament on 
the right side. Its upper border was parallel with Poupart's 
ligament. It was continuous with a mass in the pelvis to the 
.right and in front of the uterus, which was enlarged and 
retroflexed. Nothing abnormal was detected on the left 
side or in Douglas's pouch. 

It was decided to watch the case with a view to deter- 
mining how far the swelling was due to cellulitis, and to 
see whether an abscess was about to point externally. 



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282 PELVIC INFLAMMATION ATTENDED WITH 

After being under observation for a month the indura- 
tion in the abdominal wall itself had disappeared. The 
hard irregular mass in the pelvis could now^be felt more 
distinctly ; it was firmly fixed to the abdominal parietes in 
front, to the lateral wall of the pelvis on the right, and 
to the uterus behind and to the left. The patient, though 
very cheerful, was distinctly losing flesh, and it was evi- 
dent her general condition was not improving. The dia- 
gnosis was suppurative inflammation of the right uterine 
appendages. Abdominal section was now advised and 
agreed to. 

The operation was performed on February 2l8t, The 
contents of the pelvis were matted together and roofed 
in by adherent omentum. This having been partially 
separated and turned aside, it seemed at first hopeless 
to attempt to unravel the tangled mass beneath. At 
length, however, a separation was effected, first of the 
left uterine appendages, then of the caecum and appendix 
vermiformis, and lastly of the right uterine appendages. 
On the left side there was found a thin-walled adherent 
cyst, the size of a large orange, behind the broad ligament 
and adherent to the floor and back of the left posterior 
fossa of the pelvis. This was ruptured during removal, a 
quantity of serous fluid escaping. (It was afterwards 
found that this was a collection of serous fluid in the con- 
nective tissue of the broad ligament, and not a true cyst.) 
The left tube was occluded and slightly dilated, but of 
normal consistence and not thickened. On section, after 
removal, it was found to contain blood-stained muco-pus, 
the mucous membrane being swollen and oedematous. 
The left ovary was normal. The caecum and vermiform 
appendix formed part of the adherent mass on the right side. 
On bringing them into view after separation, the thick- 
ened peritoneal coat of the caecum was found to be torn. 
The rent was repaired by three Lembert's sutures of fine 
silk. The appendix was normal. The fimbriated end of 
the right tube and the right ovary (the latter enlarged 
to the size of a pigeon's egg, and lying just beneath the 



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ABSCESS OF THE OVAEY. 283 

tube) were very firmly attached to the upper part of the 
right lateral wall of the pelvis and the adjoining portion 
of the under surface of the anterior abdominal wall. On 
detaching them it was found that they had enclosed an 
abscess cavity, containing soft, purulent d6bris, evidently 
discharged from the open fimbriated end of the Fallopian 
tube. The wall of the pelvis where this abscess had been, 
presented a ragged, irregular surface. The right tube, 
much thickened, elongated, and indurated, on leaving the 
uterus first turned forwards and inwards, forming a knuckle 
in front of the body of the uterus ; it then ran directly 
outwards, the fimbriated end being attached to the pelvic 
wall, Ac, in the manner already described. The tube 
was empty ; its mucous membrane was swollen, and its 
fimbriated end highly congested. The right ovary was 
large and cedematous. On making a longitudinal section 
through it there were found two abscesses containing thick 
greenish -yellow pus : one at the outer end, near the abdo- 
minal ostium of the Fallopian tube, equal in size to a cherry; 
the other at the inner end about half that size. 

Both ovaries and both tubes were removed. There 
being an extensive hollow, with a considerable raw surface 
and much oozing of blood on the right side of the 
pelvis, it was packed with iodoform gauze. The abdomen 
was then closed. 

The gauze was removed in forty-eight hours, a large 
quantity of brownish-red fluid, without ill odour, making its 
escape at the time. An india-rubber drainage-tube was 
inserted. An enema was administered on the evening of 
the third day, which acted fairly well and gave great relief. 
Flatus passed freely. There was no sickness after the 
second day. On the fourth day the quantity of fluid 
passing by the tube was still considerable; it consisted 
chiefly of altered blood, and had now an offensive smell. 
The patient was lively and cheerful, but complained a good 
deal of flatulence. 

The stitches were removed on the seventh day. There 
was suppuration along some of the suture tracks. The 



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284 PELYIO INFLAmCATION ATTENDED WITH 

discharge from the wound had by this time become more 
pumlent, but still contained a large admixture of blood. It 
was now only very slightly offensive. There was no abdo- 
minal distension^ and the general condition was excellent. 
The appetite was good^the patient slept well^and the bowels 
responded easily to enemata. The drainage-tube was finally 
removed on March 16th (twenty-fourth day) ; the discharge 
was still purulent and fairly copious. The patient was 
gaining fleshy and was sitting up on a couch. She left 
the home a fortnight later in excellent condition. At the 
site of the drainage-tube there still existed a small sinusj 
which finally closed two months later, and gave no further 
trouble. She wrote from Broadstaii*s on June 27th to say 
she was going on remarkably well. She was suffering 
from flushes, noises in the ears, and other symptoms of 
the menopause, and complained of an occasional pain in 
the right groin ; but she was a stone heavier than when 
she left the home, and appeared to be still gaining 
weight. 

The pelvic inflammation in this case was clearly the 
result of septic infection at the time of labour. Symptoms 
of fever, preceded by an attack of shivering, set in two or 
three days after delivery, and continued for eleven weeks. 
There appears, then, to have been a period of a Uttle over 
a fortnight during which the temperature was normal* - 
But in the fourteenth week it again rose, and from that 
time various manifestations of blood-poisoning succeeded 
one another without interval up to the time of the patient's 
arrival in England in the middle of the twenty-fourth 
week after her confinement ; so that the illness had 
been practically continuous during the whole of that time. 
The patient seems to have been left to the tender mercies 
of a careless and cruel nurse-midwife, who, so far from 
having conducted the labour antiseptically, habitually 
neglected the simplest rules of personal cleanliness. 

With regard to the other possible sources of infection, 
gonorrhcea and tubercle, it was ascertained that the 
patien,t's husband had had no symptoms of gonorrhcea 



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ABSCESS OF THE OYABY. 285 

after his marriage or for the twenty-five years imme- 
diately preceding it, so that gonorrhoea may be safely 
excluded ; whilst any suspicion of tubercle was removed 
by the condition disclosed at the operation. Moreover 
I have shown, in the introductory observations, that if 
any further evidence were needed to confirm the view 
here taken (as to the origin of the infection), it would be 
found in the position occupied by the Fallopian tube, a 
position it could scarcely have acquired had it not 
contracted its adhesions at a time when it happened to 
be lifted out of the true pelvis, its normal habitat, by the 
physiological growth and development of the pregnant 
uterus. 

It will have been noticed that I was in no hurry to 
operate. It appeared just possible, from the seat of the 
induration, that the primary mischief had occurred in the 
connective tissue, and that an abscess had formed at the 
back of the pelvis, had spread to the iliac fossa, and was 
about to make its way to the surface. The case, there- 
fore, was kept under observation for a month, in the hope 
that abdominal section might be avoided. At the end of 
that time the signs of cellulitis, so far from having 
increased or extended, having under the influence of 
complete rest almost disappeared, clearly showed that 
the cellulitis had been secondary. A further result of 
the diminution in the amount of superficial induration 
was that there could now be made out, on bimanual 
examination, a distinct, hard, irregular mass in the 
situation of the right uterine appendages. There was, 
therefore, no need to defer operation any longer. It was 
clear, from the persistence of the pyrexia and other 
symptoms, that suppuration was present ; and now that it 
had been shown to be intra- and not extra-peritoneal, the 
sooner the abdomen was opened and the pus removed the 
better. The condition disclosed was purulent inflamma- 
tion of both Fallopian tubes, the purulent contents of the 
right tube having escaped from the abdominal ostium and 
formed an intra-peritoneal abscess between the fimbriated 



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286 PELVIC INFLAMMATION ATTENDED WITH 

end of the tube and the pelvic wall, to which latter the 
fimbriae had become adherent. The ovary, enlarged and 
adherent, formed part of the wall of this abscess, and had 
become secondarily infected. It was found on section to 
contain two distinct abscesses, one of them closely contigu- 
ous to the intra-peritoneal abscess, the other at the inner 
end of the ovary. Those who oppose surgical interference 
in these cases are accustomed to speak of operations 
undertaken for their relief as operations undertaken for 
the relief of pain rather than for the saving of life. I 
firmly believe that they save life much more frequently 
than is generally conceded, and that the case here related 
is an instance in point. If it be said, " Certainly in a 
case of ovarian abscess the operation is of a life-saving 
character, and is therefore justifiable," I would ask how 
in this case it could possibly be known, before the 
operation disclosed it, that there was an abscess in the 
ovary. Had the operation been delayed until the danger 
to life had been made apparent by the development of 
those violent symptoms that follow the bursting of such 
an abscess, the interference would probably have come 
too late. As it is, the patient has escaped this danger ; 
and although the operation was one of great difficulty, 
and attended with considerable immediate risk, I believe 
it not only to have been justifiable, but to afford a striking 
instance of the saving of a life by timely intervention. 

The next case is, in its main features, curiously 
parallel to the one just described. Here, too, the 
inflammation resulted from septic infection at the time of 
labour, and so far simulated, at first, primary cellulitis 
affecting the posterior part of the pelvis, that operation was 
for a time on that account deferred. 

Case 2. — H. W — , aged 40, married, residing at 
Sydenham, was admitted into St. Thomases Hospital 
February 23rd, 1894. She had been married twelve 
years, and had borne six children. She was delivered of 
her first child by the aid of instruments, the child being 



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ABSCESS OP THE OVARY. 287 

stillborn. For some montlis afterwards she had a thick 
yellow vaginal discharge, and although she had no 
internal pain, and was never ill enough to necessitate con- 
finement to bed, she found sitting so painful that she was 
in the habit of carrying a soft cushion about with her. 
She had had no pain during her first pregnancy, but 
during all her subsequent pregnancies she states that she 
suffered more severely than anyone can know. Her last 
labour took place January 10th, 1894, and lasted two days 
and nights. The child was puny, and it died within 
forty-eight hours of its birth. She says she was told that 
the cord and afterbirth were ^^ rotten/' She left her 
bed at the end of a fortnight, feeling all right. A week 
later she was seized with an attack of shivering, followed 
by incessant retching and vomiting for twenty-four hours. 
She had been in bed ever since, i. e, for a period of three 
weeks, suffering from occasional attacks of shivering, 
symptoms of pyrexia, and severe pain in the hips and 
lower part of the back and down the right thigh. For 
three days before admission she had diarrhoea, with loose 
watery stools. 

On admission the patient was very ill and in con- 
stant pain. The right thigh was flexed on the trunk, 
any attempt to straighten it causing great pain in the groin. 
The temperature was 101'4*'; the pulse 104. The urine 
was loaded with urates, and contained a trace of albumen. 
Sp. gr. 1020. The tongue was furred, and there was 
inability to take solid food. 

On deep palpation of the lower part of the abdomen 
the uterus was felt as a tender, firm, fixed body a little 
to the right of the middle line, with its upper border 
4 inches above the symphysis pubis. The length of its 
canal was 2^ inches. On examination under ether a hard, 
irregular, nodular swelling was felt firmly attached to the 
back of the uterus ; it passed upwards and to the right, 
where it became firmly attached to the brim of the pelvis. 
Nothing abnormal could be detected on the left side. The 
diagonal conjugate diameter of the pelvis was 4| inches. 



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288 PELVIC INFLAMMATION ATTENDED WITH 

There was no depression of the lateral fomices of the 
vagina. 

The patient's condition, so far from improving under 
t^e influence of rest, became steadily worse. The pain in 
the right groin increased in severity. The evening tem- 
perature remained high, reaching from 101"2° to 102*4° 
almost every day. The anorexia persisted. The bowels 
were constipated. 

It was inferred from these symptoms that there was 
suppurative inflammation of the right uterine appendages, 
although no physical evidence of the presence of pus was 
forthcoming. 

At the end of a fortnight, therefore, it was decided 
that an operation ought to be performed. The patient 
and her friends readily gave their consent. 

Abdominal section was performed on March 8th, 1894. 
The mass on the right side, having been exposed and 
brought into view, was found to consist of uterine appen- 
dages and ceecum matted together, the whole mass being 
firmly adherent to the pelvic wall. The Fallopian tube 
was seen running along the upper border of the mass. 
While the adhesions were being separated some pus 
escaped. The cascum was much thickened by inflamma- 
tion and extremely adherent. Fortunately the parts 
could be kept in view whilst this adhesion was being 
separated. The appendix vermiformis was quite free 
from the mass and healthy. A roughened and ragged 
surface was found on the wall of the pelvis. It had 
clearly formed part of the wall of an intra-peritoneal 
abscess between the pelvic wall and the matted uterine 
appendages, on which a similar surface was seen. This 
abscess was evidently the source of the pus that had 
escaped during the operation. The Fallopian tube com- 
municated with this abscess through its open fimbriated 
end, which easily admitted a large probe. The ovary, 
which formed part of the wall of the abscess, did not 
communicate with it. The mass, having been separated, 
was lifted up, tied off, and removed. A portion of the 



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ABSCESS OP THE OVARY. 289 

psoas muscle adjacent to the abscess was felt to be in- 
durated by inflammatory exudation. A wound on the 
posterior surface of the uterus caused by the separation of 
adhesions was repaired by means of three sutures of fine 
silk. A serous cyst on the anterior surface of the broad 
ligament was emptied by puncture. The appendages on 
the left side were examined and found to be perfectly 
healthy. The abdominal cavity was cleansed by sponging. 
•The vagina and rectum were examined and found to be 
uninjured. A glass drainage-tube was inserted and the 
abdominal incision closed. 

The parts removed measured en masse 2^ inches x 2 
inches x 1^ inches^ and consisted of part of the right 
Fallopian tube, the right ovary, and a portion of the right 
broad ligament. The Fallopian tube was empty, but the 
mucous membrane was inflamed and oedematous. In the 
ovary, which, as has been already said, formed part of the 
abscess wall, were found two abscesses, one the size of a 
walnut, the other rather larger. These two abscesses 
communicated with one another by an ulcerated aperture, 
J inch in diameter, surrounded by inflamed ovarian tissue, 
and presented on their internal surface a similar ragged 
appearance. This surface was greyish yellow in colour, 
and was covered with purulent lymph. In other parts 
the tissues of the ovary appeared fairly healthy. 

The temperature for the first twenty-four hours was 
normal and subnormal. On the second and third days it 
ranged between normal and 100*4°; after which it never 
reached 100®, and was generally normal. On the third 
day an india-rubber tube was substituted for the glass one, 
and a simple enema was administered, with the result that 
a large quantity of flatus was expelled. On the fourth 
day another enema was given with very good result, and 
the patient from that time was able to pass urine natu- 
rally. The sutures were removed on the ninth day, and 
on the twelfth day the drainage-tube was removed. The 
discharge became purulent on the third day, and after the 
removal of the drainage-tube the sinus still continued to 



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290 PELVIC INFLAMMATION ATTENDED WITH 

discharge a little pus. There was considerable shock for 
the first two days, after which the patient rapidly im- 
proved in condition, and began to gain flesh. The right 
thigh regained its normal power of extension within a 
very few days after the operation. The patient left 
the hospital on the 9th of May, looking so stout and 
well and cheerful, and with so clear a complexion, that 
she was scarcely recognisable as the haggard, sallow, 
emaciated, miserable creature that she was on admission. 
There was still a very small sinus at the lower angle of 
the wound. She called to report herself on her return 
from the convalescent home three weeks later. She was 
in excellent condition, and felt better than she had done 
for several years. The sinus had not quite healed. 

The condition of things disclosed in this case at the 
operation was so similar to that in Case 1, that the remarks 
upon that case apply almost equally well to this. Here^ 
too, I firmly believe that the result of the operation was 
not only to restore health, but to save life. The mischief 
in the ovary had advanced a stage further than in the 
other case. There were, as in that case, two abscesses, but 
these, instead of being distinct, had communicated with 
each other by a process of ulceration. 

One other point in the case merits a moment's attention, 
on account of the light it sheds on the immediate cause of 
the inability to extend the thigh upon the trunk in many 
cases of puerperal pelvic inflammation. The focus of 
greatest intensity of the inflammation, which was on the 
pelvic wall where the abdominal ostium of the Fallopian 
tube had become adherent, and where an intra-peritoneal 
abscess had formed, was over the inner edge of the psoas^ 
with the result that local induration of the muscle had 
occurred from inflammation of its connective-tissue ele- 
ments. After the removal of the pus the muscle quickly 
recovered its function, and within a week the patient 
was able to extend her thigh completely and without pain 
or difficulty. This helps us to understand how, at least 
in some instances, the flexion and stiffness of the thigh are 



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ABSCESS OF THE OVABY. 291 

produced^ and how it is that efforts at extension are 
attended with snch severe pain. 

The third and last case^ though also one of ovarian 
abscess^ differed in many particulars from the foregoing. 
It was almost certainly gonorrhoeal in its origin ; it had 
advanced to the stage of rupture^ and the operation for 
its relief was too late to save life. 

Case 3. — ^L. C — , aged 22, single, a domestic servant, 
was admitted into St. Thomases Hospital as a case of 
emergency late in the evening of the 24th February, 
1894, at the request of Dr. Burgess, of Streatham. 

The patient was a fair-complexioned girl, with flushed 
cheeks, looking extremely ill, and .complaining of acute 
pain and tenderness in the lower part of the abdomen, 
chiefly on the left side, where there was a swelling to be 
presently described. The temperature was 103'2°, the 
pulse 128, the tongue dry and coated with a white fur. 

The following very imperfect history was all that could 
be obtained. The patient had only menstruated four or 
five times in her life, the first occasion being at the age of 
eighteen. She last menstruated about eighteen months ago. 
The flow, even when it did appear, was scanty, and did 
not last more than one or at the most two days. Except 
for an attack of pleurisy at the age of sixteen, the patient 
states that she enjoyed good health until the month of 
January, 1 893, when, after a period of amenorrhcea lasting 
some four or five months, she was taken ill with pain and 
swelling in the abdomen. This illness lasted for several 
months. The swelling is said to have disappeared about the 
month of July, after which she gradually gained strength, 
and in November she states that she was as well as she has 
ever been. During the illness she is said to have had several 
transient attacks of paralysis, evidently of a functional 
character. Prom November she remained apparently quite 
well, and was at work up to February 21st, 1894, three 
days before her admission, when she was suddenly seized 
whilst at her work with acute pain in the lower part of 



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292 PELVIC INFLAMMATION ATTENDED WITH 

the abdomen^ chiefly on the left side, accompanied with 
vomiting and rise of temperature, and soon followed by 
swelling of the abdomen. She was so ill that she had 
to go to bed, where she remained until she was sent up to 
the hospital. On the day before her admission (February 
23rd) there was retention of urine, and the catheter was 
required. 

On admission a swelling was observed in the lower part 
of the abdomen, rising out of the pelvis, and extending to 
the left side and upwards nearly to the level of the 
umbilicus. There was an obscure sense of fluctuation 
over the most prominent part. On vaginal examination the 
cervix uteri was found to be pushed against the symphy- 
sis pubis by a fluctuating tumour which bulged down the 
posterior fornix. The uterus lay immediately beneath 
the abdominal wall, a little to the left of the median line. 
The uterine sound passed the normal distance, 2i inches. 

During the two days following the patient^s admission 
the temperature ranged between 101*2° and 102*8°. The 
general condition remained the same. The tenderness and 
paroxysmal pain were very -acute. 

It was evident that there was acute pelvic suppuration 
due to some pre-existing disease of the uterine appendages, 
and that the only hope for the patient was to evacuate 
the matter by operation. It was decided to perform 
abdominal section. The consent of the friends having 
been obtained, the operation was performed at 2 p.m. on 
February 26th. Immediately on reaching the peritoneal 
cavity and separating some adherent omentum, a quantity, 
estimated as at least a pint (16 fl. oz. being collected and 
measured in addition to what escaped), of thin, flaky, 
highly offensive pus flowed out. The upper part of the 
wall of the abscess was formed entirely by thickened 
and inflamed omentum, which formed as it were a dome 
over it. Behind and below the abscess was bounded by 
the posterior wall of the pelvis and the rectum, the latter 
much inflamed and thickened. In front lay the right 
broad ligament, enormously thickened by chronic cellulitis, 



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ABSCESS OF THE OVAEY. 293 

and the right uterine appendages^ in which the abscess had 
evidently originated. The uterus, rotated with its right 
side forwards and upwards, lay to the left and in front of 
the abscess. After thoroughly douching the abscess cavity 
an assistant was directed to place his finger in the rectum, 
and the right uterine appendages were separated from their 
adhesions, brought into view, and removed. The right 
Fallopian tube was so friable that it was torn in several 
places during the separation. It was much thickened from 
chronic inflammation. The ovary was represented by a 
thick- walled, empty abscess cavity 2x1^ inches in dia- 
meter. In its wall was a rent large enough to admit the 
finger. Its inner surface was ragged and ulcerated, and 
covered in places with granulation tissue. The wall 
appeared on section to be composed of condensed ovarian 
tissue. The broad ligament at the line of section measured 
I inch in thickness. 

The left appendages were next separated and removed. 
The ovary was converted into a small cyst, containing 
clear yellow fluid. The tube was thickened by chronic 
inflammation to such an extent that its wall in places 
measured | inch in diameter. It was tortuous and 
elongated. Its mucous membrane was pale and highly 
oedematous. The tube was empty, and its fimbriated end 
was open. There was excessive cellulitic thickening of 
the left broad ligament. A considerable portion of the 
inflamed and matted omentum, which had roofed in the 
abscess, was now ligatured in sections and removed. It 
was lined by a layer of adherent purulent lymph. The 
cavity was again flushed with a hot douche of solution of 
boracic acid ; a glass drainage-tube was inserted, and the 
abdominal incision closed. 

The operation lasted two hours, and was attended with 
much shock, especially during the removal of the right 
uterine appendages, when it became necessary to inject 
twenty minims of brandy subcutaneously. 

The patient^ 8 temperature after the operation was 97^, 
but it rapidly rose in the evening to 101^ ; the pulse at 

VOL. XXXVI. 21 



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294 PELVIC INFLAMMATION ATTENDED WITH 

the same time becoming very rapid, weak, and irregular. 
At 5 o^ clock next morning she became unconscious, 
delirious, and noisy, and she died at 5.30. 

A post-mortem examination was made the following day 
by Dr. Herbert P. Hawkins, from whose notes the following 
is an extract. '^ There was a S^-inch median, sutured, 
unhealed incision between umbilicus and symphysis. On 
opening this up, it was found to lead into an abscess 
cavity of considerable size, situated almost entirely in the 
pelvis, containing about an ounce or so of dark brown, 
non-offensive, thin fluid. 

" There was no affection, past or present, of the general 
peritoneum. The floor of the abscess, which lay practi- 
cally in Douglases pouch, was formed by the large flattened 
rectum below, and above by the free edge of the omentum, 
which dipped down into the pelvis. On the left it sur- 
rounded a large loose portion of the sigmoid flexure ; on 
the right it was bounded by the pelvic wall and the psoas, 
but did not extend on to the iliac fossa. In front it was 
bounded by the uterus. Its wall was covered with tough 
shreds of false membrane, and the lower part of the 
rectum, where it came into relation with the abscess, was 
partially denuded of its peritoneum. The sigmoid flexure, 
the summit of the uterus, and a coil of small intestine 
showed signs of the recent separation of adhesions. There 
was no perforation of the bowel. On the right side, just 
external to the lower end of the psoas, a ragged aperture 
in the peritoneum led into an abscess cavity in the retro- 
peritoneal tissue which could contain the last phalanx of 
a man's forefinger. 

" The lax tissue between the bladder and symphysis was 
highly cedematous. 

** The uterus itself showed no disease internally ; it was 
of normal size, the cervix and the body being, however, 
of nearly equal length. 

" Both uterine appendages had been removed, and the 
stumps remained well secured. Neither ovary could be 
found. 



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ABSCESS OF THE OVABY. 295 

" The right ureter showed a little distension for a length 
of two inches above the pelvic brim, due to the thickening 
of the retro-peritoneal tissue in the pelvis. The upper 
part of the ureter was normal, but the pelvis of the kidney 
showed unmistakable evidence of commencing hydrone- 
phrosis. The left ureter was normal. The bladder was 
thick-walled, but otherwise healthy. The kidneys were 
hyperaemic. The pleursB and pericardium were normal. 
The lungs showed dark congestion of the lower lobes. The 
heart was healthy in all respects. 

'^ The liver was soft and flabby. The gall-bladder was 
distended with clear colourless fluid ; it contained a stone 
the size of a hazel-nut, and another of similar size com- 
pletely blocked the cystic duct. 

" The spleen was very large and soft. The brain showed 
no trace of past or present disease." 

The chief value of this case is the illustration it affords 
of one of the natural modes of termination of cases of 
ovarian abscess when these abscesses are left to take 
their own course : the imprisoned pus, gradually it may 
be, but surely, makes a way of escape for itself by a 
process of ulceration ; the wall of the abscess becomes 
thinned by this process, and eventually gives way, either 
by rupture or by perforation, and the contents of the 
abscess escape. Sometimes the wall of the ovary has 
acquired adhesions to neighbouring parts, and the abscess 
is evacuated into the rectum, or into the vagina, or into the 
bladder. In the instance before us the pus escaped into 
the peritoneal cavity. Owing to the presence of adhesions 
it did not become diffused, but formed an intra-peritoneal 
abscess, which rapidly increased in size, so that within a 
few days it had formed a swelling that not only filled the 
pelvis but extended into the abdomen, and was plainly 
perceptible there as a distinct fluctuating tumour nearly 
reaching the level of the umbilicus. 

The case also illustrates very forcibly the illusory 
character of a temporary subsidence of symptoms in some 
of these cases of severe pelvic inflammation. Had this 



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296 PELVIC INFLAMMATION ATTENDED WITH 

case been reported whilst the patient was at work and 
in apparently perfect healthy it might conceivably enough 
have been quoted as an instance of cure without operation. 
I am persuaded that if cases of alleged cure by rest and 
medicinal treatment were followed up^ not a few of them 
would turn out to have been instances of a kind similar 
to this, where for a time the purulent collection gave no 
indications of its presence, but where it was all the 
while quietly laying the train for a fresh outburst, and 
constituting a grave menace to the patient's life. 

I have elsewhere ("An Address on Pelvic Abscess,*' 
'Birm. Med. Review,' November, 1893) called attention 
to the unsuspected frequency of small suppurating 
ovarian cysts amongst the causes of acute pelvic peri- 
tonitis, and have shown that, next to purulent salpingitis, 
these cysts constitute the most common form of pelvic 
suppuration. Up to the end of October, 1893, I had 
performed abdominal section in eighty-three cases of pelvic 
suppuration (non-cellulitic) . In no fewer than thirty 
of these I found one or more suppurating cysts of the 
ovary. In twenty-five of the thirty this condition was 
associated with salpingitis ; with active purulent salpingitis 
in thirteen, and with chronic salpingitis in twelve. 

These figures strongly support the view that, in the 
great majority of cases, suppuration in the ovary, whether 
in the form of small suppurating cysts or simple abscesses 
(which are very diiBBicult to distinguish from small suppu- 
rating cysts), is secondary to purulent salpingitis. 

I trust that the Society will not think that its time has 
been altogether wasted in listening to this communication. 
Our knowledge of suppurative inflammation in the pelvis 
is still so imperfect, that even so small a contribution to 
its study as is afiEorded by the history of these three cases 
may not be wholly unprofitable. 

Dr. Hayes could not think that Dr. Cullingworth's idea, that 
cases of ovarian abscesses and pelvic cellular abscesses, such as 
those related in his paper, were dependent upon a prior puru- 
lent accumulation in a Fallopian tube, was at all proven. Dr. 
Hayes remarked that in the first two cases septic infection was 



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ABSCESS OF THE OVABY. 297 

the first step in the morbid phenomena, and snrelj this was 
often the cause or precursor of inflammation terminating in 
abscess ; abscess in the cellular tissue, ovary, or tnbe, in any 
two, or in all three. Why assign the tube as the infecting 
source of the ovary or cellular tissue? He saw nothing in 
these two cases to substantiate such a view, and preferred to keep 
his mind in suspense rather than dogmatise. He would prefer 
the same attitude of mind regarding the third case in the paper. 
He failed to understand the author's explanation of how so 
large a collection of pus, so rapidly formed within the perito- 
neum without general infection, could come from some abscess 
in the ovary comparatively so small. Dr. Hayes was in full 
accord with Dr. Cullingworth's method of treatment. 

Dr. G-ALABiN said that he had met with several cases similar 
to those recorded by Dr. Cullingworth, and he agreed with him 
that the usual sequence of events was that the suppurative 
inflammation was communicated from the tube to the ovar^. 
He considered that the liability of the ovary to suppuration m 
these cases afforded a strong argument in favour of removing 
both ovaries in cases of double pyosalpiux, since there might be 
small foci of commencing suppuration which might escape 
recognition at the operation. In one case he had reason to 
regret that this had not been done. The patient was a single 
lady, aged twenty-five, on whom he performed abdominal sec- 
tion on account of a painful lump on the right side. On the 
right side a peritoneal abscess and pyosalpiux were found, on 
the left pyosalpiux. The tubes were lined with cheesy material, 
apparently tubercular. The left ovary was removed with the 
tube, the right ovary could not be found. The patient con- 
tinued to menstruate, and a sinus discharging pus remained at 
the site of the drainage-tube. From time to time pus became 
retained, and the temperature rose. About a year and a half 
later an increasing swelling began to be felt on the right side, 
and was thought to be suppurating cystoma of the remaining 
ovary. He decided to repeat abdominal section, and operated 
by a lateral incision. The coils of intestine had to be dissected 
apart bv knife and scissors before the lump in the pelvis could 
be reached. It proved to be ovary enlarged to more than two 
inches in diameter, and containing several abscess cavities, one 
discharging by a sinus. The patient recovered from the opera- 
tion after a severe illness, but unfortunately became insane, 
having a family proclivity that way, just as the sinus in the abdo- 
minal wall had closed. In another case recently he operated 
for double pyosalpiux on a girl aged twenty-one, and was 
anxious to preserve an ovary if possible, as she was engaged to 
be married. Finding, however, that they appeared inflamed 
and enlarged, and were adherent to the fimbriated extremities 
of the tubes, he removed them both. On incising them they 



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298 PELVIC INFLAMMATION ATTENDED WITH 

were found to contain several small abscess cavities, apparently 
suppurating follicles. Puncture during the operation had 
failed to reveal these. He thought that if the ovaries had been 
left in this case the sequel might have been similar to that in 
the former one. The patient recovered without any sinus 
remaining. 

Dr. Duncan thought the Society greatly indebted to Dr. 
Cullingworth for the valuable contribution just read. He quite 
agreed with the author that in any case where pelvic suppura- 
tion was suspected the proper treatment was to perform abdo- 
minal section, as there was usually found to be pus either in the 
tubes or ovaries. Dr. Duncan mentioned a case he had recently 
seen in consultation, in which a lady had had for months an 
extremely irregular temperature with occasional slight rigors, 
but where the symptoms had been diagnosed as "neurotic;" 
there was distinct pelvic tenderness and thickening in the 
f ornices, but though he (Dr. Duncan) diagnosed pelvic suppura- 
tion and advised exploratory laparotomy, the other physicians 
who saw the patient were averse to operation. 

Dr. G-BiFFiTH remarked that Dr. Cullingworth had not 
attempted to explain or to prove the most important patho- 
logical theory in his valuable contribution, namely, that ovarian 
abscess was the result of tubal inflammation ; the explanation 
of this, if the fact were proved, would not be easy. It did not 
seem probable that an inflammation extending from the tube to 
the surface of the ovary would readily cause suppuration of the 
substance of the ovary. There is a group of cases, however, 
not referred to by Dr. Cullingworth, which explains a certain 
number of these cases, and their explanation is obvious. Dr. 
Griffith believed that suppuration of the ovaries was usually 
the result of septic inflammation occurring in connection with 
childbirth, abortion, or surgical operations extending through 
the broad ligament; the stroma, lymphatics, and blood-vessels 
of each being in direct continuity. In the severe fatal cases 
sloughing or suppuration of the ovaries is not rarely seen, and 
in the less severe cases abscess of the ovary remained after the 
parametritis had subsided, and kept the patient an invalid, or 
at least liable to constant fresh attacks of illness unless spon- 
taneous evacuation occurred, or the ovary was removed by 
operation. Inflammation of the tubes was* commonly present 
in different degrees in these cases. 

The President said that Dr. Cullingworth's paper put before 
them instructive illustrations of the increase in our power of 
curing disease which pelvic surgery had brought about. He 
had seen two cases of ovarian abscess different from those 
related by Dr. Cullingworth. In each of these two cases there 
was a small cyst, full of pus, which he had enucleated from itg 
bed in the ovary quite easily without rupture and without 



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ABSCESS OF THB OVABY. 299 

hfiBmorrhage. The history of one of these cases might be 
interesting. She was married in 1871. Six weeks after 
marriage she had a severe ilhiess attended with great pain, for 
which she was in the London Hospital under the care of the 
late Dr. Head. She was delivered in 1873, and afterwards had 
an illness described as '* inflammation and fever." In 1874 she 
had a relapse of this illness, and was in the hospital under the 
care of the late Dr. Palfrey ; the diagnosis then made was 
"pelvic cellaHtis." In 1876 and subsequent years she was 
under the care of Dr. Herman as an out-patient ; but she got 
no better, being in continual pain, and occasionally acute 
attacks laying her up. At last she got tired of ineffectual 
treatment, and ceased attendance. Dyspareunia had been severe 
since the illness, six weeks after marriage. In 1891 she again 
came for treatment, prompted by special reasons, but much the 
same in health. Dr. Herman now recognised the case as one 
which could be dealt with surgically ; he opened the abdomen, 
and removed the suppurated cyst be had described. The 
patient lost her pain, gained flesh, and considered herself well. 
This case showed the cbronicity of the morbid process, and also 
the advance of our power to cure; for doubtless this patient 
might have been saved twenty years of pain bad our present 
knowledge been possessed when she fii'st came under treatment. 

Dr. Lewers said that Dr. Griffith had spoken of the con- 
nection between inflammatory affections occurring during the 
puerperium and abscess of the ovary. Some years ago Dr. 
Lewers read a paper before the Society describing a phlegmon 
of the broad ligament occurring in a patient who had died 
within a short time after her confinement. In that case, while 
the inflammatorv process between the layers of the broad 
ligament was only in the stage of phlegmon, there being no 
suppuration there, yet in the adjoining ovary there was found, 
on section, a small abscess containing about a drachm of pus. 

Dr. CuLLiNawoBTH, in reply, said that so far from his having 
entered upon the inquiry as to the source of infection in cases 
of ovarian suppuration with a bias in favour of the views he 
had propounded, the very reverse was the case, for he had realised 
all along the difficulty, to which Dr. Griffith had given expres- 
sion, of explaining how the infection travelled from tube to ovary. 
He therefore hoped Dr. Hayes would acquit him of the charge 
of making the facts suit the theory. It did not seem necessary 
to invoke pysemia as the cause when there was such strong 
evidence of a local infection. Dr. Hayes had inquired where 
the enormous quantity of pus had come from that was found on 
opening the abdomen in the third case. The answer was that 
when perforation or rupture of a suppurating ovary or tube 
occurred, and the contents escaped amongst the surrounding 
peritonitic adhesions, a very active suppurative process was 



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800 ABSCESS OF THE OVABT. 

often set up, the resulting abscess rapidly assuming a very 
large size and forming an abdominal swelling of considerable 
dimensions. The source of the accumulation in the case under 
discussion was the rupture of a suppurating ovary. He was 
grateful to Dr. Galabin for his estimate of the importance of 
the evidence he had brought forward as to the large proportion 
of cases in which suppuration of the ovary was associated with 
tubal disease, and for having called attention to the desirability 
of removing even apparently normal ovaries in operations for 
pyosalpinx. In reply to Dr. Griffith, he expressed his belief 
that the infection passed from tube to ovary durectly through 
their respective walls, or from an intervening intra-peritoneal 
abscess. He considered the case analogous to the infection of 
certain dermoid tumours of the ovary supposed to originate 
from the contents of tbe adjacent rectum when the tumours 
had been bruised during the process of parturition, and thus 
rendered susceptible to infection. He thanked the President 
and Fellows for the interest they had taken in the paper. Its 
perhaps too didactic style was due to its having been begun 
with tbe intention of deUvering it as a clinical lecture, a purpose 
for which it subsequently appeared to be unsuitable. 



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NOVEMBER 7th, 1894. 

G. Ernest Herman, M.B., President, in the Chair. 

Present— 49 Fellows and 4 visitors. 

Books were presented by Mr. Walter Heape, the Gay's 
Hospital StafiE, and Dr. Galabin. 

Robert Francis Burt, M.B, C.M.Edin., and David 
Petty, M.B., C.M.Edin., were admitted Fellows. 

The following gentlemen were elected Fellows of the 
Society : — Walter Meent Borcherds, M.R.C.S. (Cape 
Colony) ; Arthur Mantell Daldy, M.D., B.S.Lond. j 
Thomas Vere Nicoll, L.R.C.P.Lond. ; Adam William 
Thorburn Steer, M.R.C.S. ; William Atkinson Stott, 
M.R.C.S. ; Allen James Swallow, M.B., B.S.Durh. ; John 
D. Williams, M.D.Edin., B.Sc. 

The following gentlemen were proposed for election : — 
H. Bellamy Gardner, M.R.C.S. ; R. W. Johnstone, 
M.D., B.Ch. ; Robert Thomas Alexander O'Callaghan, 
F.R.C.S.I. ; Herbert Edward Rayner, F.R.C.S. 



Report on Dr, Eden's Specimen of Tubal Mole exhibited 
on Jan. Srd, 1894 (p. 5). 

The clot in the tube, examined under the microscope, 
contains numerous and distinct chorionic villi scattered 



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302 PEFOBHED F(ETUS. 

throughoat its substance. This appearance is distinct 
proof of tubal gestation. 

Alban Doban. 

T. W. Eden. 

J. Bland Sutton. 



Report on Dr. Leith Napier's Specimen of Deformed 

Foetus, 

External appearances. — The foetus is found to measure 
11 inches in total lengthy and appears to be in the seventh 
month of development. It is the subject of retroflexion 
and right latero-flexion, the flexion being most marked in 
the cervical and upper dorsal regions. 

On its abdominal surface is a mass the size of a large 
orange^ consisting of viscera^ and attached by a pedicle 
composed of amnion and peritoneum closely united. In 
this pedicle, between the amnion and peritoneum, run the 
vessels of the umbilical cord, surrounded by Wharton's 
jelly ; the vessels start on the under aspect of the pedicle 
and turn round at once to its left side ; they then pass 
forwards and upwards to what appears to be the apex of 
the sac. This is where the attachment to the placenta 
has been divided. The ligature included the vessels of 
the cord, Wharton's jelly, and the continuation of the 
amnion lying on their upper surface. The amnion does 
not completely cover the extruded viscera. In the 
uncovered area the chorion must have come directly into 
contact with the peritoneum. The peritoneal sac was 
probably formerly complete. The viscera contained in 
the sac include the greater part of the abdominal con- 
tents, the heart lying within the pericardium, and the 
left lung. 

The face and vertex are normal. The head is rotated 
towards the right ; the hairy scalp descends to within a 
short distance of the iliac crest. A tumour arises from 
the left occipital region, and the attachment of this 



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DEFORMED FCETUS. 308 

tumoor extends down the left side of the trunk nearly to 
the iliac crest. The chin is on the same plane as the 
front of the thorax ; the right ear lies in a fold composed 
partly of loose skin, and partly of subcataneous tissue. 
The prolabium is well marked ; the palatal processes are 
deficient in the middle line. 

With the exception of talipes varus of the right foot, 
the other external appearances are normal. 

Dissection, — An incision was now made in the anterior 
surface of the trunk from the chin to the upper edge of 
the abdominal sac. The thorax was found to be thickly 
covered with subcutaneous fat. The intestine was divided 
about the level of the rectum, and the alimentary canal 
separated as high as the oesophagus. 

Alimentary canal. — The course of this is found to be 
normal throughout. The caBCum and vermiform appendix 
are well developed ; there is no appearance of vitelline 
duct. The pancreas is of normal size. The diaphragm 
seems to be represented by a few muscular strands which 
surround the cardiac orifice of the stomach, and by a 
tendinous expansion interspersed with muscular fibres 
running between the pericardium and the upper surface 
of the liver. 

Heart. — The pericardium contains a small quantity of 
grumous fluid. The heart was of normal size, and the 
main vessels connected with it appear as usual. 

The umbilical vessels may be traced back from the 
insertion of the cord ; the two arteries run one on each 
side of a well-developed uraohus. The vein enters the 
liver in the normal way. 

Lungs, — The left lung lies in the sac ; the right is 
situated inside the thorax, with normal foetal relations. 
Neither lung contains air. The large vessels of the neck, 
trachea, oesophagus, and thymus are normal. 

Kidneys, — The kidneys are united inferiorly by a 
median lobe, thus presenting an example of '* horseshoe 
kidney.'' The transverse measurement of the composite 
organ is 1 } inches ; the greatest vertical measurement is 



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804 DEFORMED FCETUS. 

1 inch on each side. The uretef*s start from 'the middle 
of the inner border of each half of the kidney mass^ and 
descend in front of the median lobe. 

Of the abdominal vessels the right internal iliac artery 
is missing ; the right hypogastric artery arises from the 
right external iliac. The left internal iliac artery gives 
off branches to the right side across the middle Hue. 

An incision was made in the scalp following the lines 
of the sagittal and lambdoidal satnres, the skin reflected, 
and the thinned portion covering the meningeal sac dis- 
sected off. 

Head. — The tumonr mentioned as being attached to the 
occipital region on the left side proved to be a meningo- 
encephalocele, the pedicle of which piasses out between 
the skull and the vertebral column. On opening the sac, 
which is about the size of a hen's egg, it is found to 
contain a quantity of turbid watery fluid mixed with 
decomposed brain-matter. 

On the right side, between the slioulder and the head, 
is another cyst, the size of a pigeon's egg, which, however, 
caused no projection of the surface. Its pedicle arises 
from the thyroid tissues in front of the trachea, and its 
contents consist of clear fluid mixed with a quantity of 
yellowish semi-gelatinous matter. 

Skeleton. — ^Limbs and limb-girdles. — Thesewerenormal 
with the exception of talipes varus of the right foot. 

Skull. — Palatal process of the maxillary bone of each side 
is deficient, leaving the vomer and turbinated bones visible 
from the mouth. The anterior margin of the foramen 
magnum is deficient in consequence of the absence of the 
basi-occipital portion, whereby the basi-sphenoid bounds 
anteriorly the much enlarged foramen between the cavities 
of the skull and spinal canal. With these exceptions the 
skull is normal. 

Vertebral column. — The cervical and upper dorsal 
vertebrae are involved in a sharp curve whose concavity 
looks backwards and to the right. Owing to this curve 
the posterior portion of the skull is in apposition with the 




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irv ih^ forrnxxtion/ of th^ scu^.arucL^hje^ sztuLa1xx)-tu oftheumhdi/xrL 

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chx)i^ix>ri,of'th'e^plxLcej''Ltou. 



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DEFOBHED F(ETU8. 305 

right posterior surface of the vertebral column. The 
laminse of the vertebrae involved in the curve have 
remained widely separated, — as far down^ in fact^ as the 
second lumbar ; and as a result of this separation^ and of the 
deficiency of the foramen magnum above mentioned^ the 
cerebral and spinal cavities are thrown into one^ and the 
under surface of the brain rests in part on the posterior 
surface of the bodies of the vertebrse. 

The second lumbar vertebra is complete. The third, 
fourth, and fifth lumbar vertebras have no spines, nor are 
their laminaa properly united; but the spinal canal is 
roofed over by a firm triangular plate of bone, whose apex 
coincides with the spine of the second lumbar, and whose 
base, ^ inch wide, is at the inferior border of the fifth 
lumbar vertebra. This plate of bone is 1 inch long. The 
sacrum is normal ; but between it and the last lumbar 
vertebra is a spina bifida occulta. The ribs on the left 
side are well developed, and articulate with the left border 
of the sternum. On the right side the ribs are incomplete 
and imperfectly developed. 

Remarks. — The specimen is an instance of the absence 
of an umbilical cord in combination with retro- and 
latero-flexion, extroversion of viscera, and non-closure of 
parts of the cerebro-spinal canal. 

The following explanation is suggested. 

There was no umbilical cord developed from the allan- 
toic stalk. The foetus was therefore unable to leave the 
uterine wall, as the centre of its body was attached by 
the umbilical vessels to the chorion adherent to the 
uterine surface. On account of this application the 
edges of the abdominal wall were unable to close round 
an umbilicus. This inability to close was due also to the 
diminution of the available body-cavity caused by the 
convexity forward of the vertebral column (retroflexion), 
resulting in protrusion of viscera. The retroflexion was 
brought about by the application of the anterior surface 
of the embryo to the concave uterine wall. The pro- 
trusion of the viscera was possibly due in addition to 



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806 DEFORMED FCETUS. 

attempts on the part of the tmnk to grow in its normal 
attitude of flexion to the fronts as by such attempts the body- 
cavity would be withdrawn off its contents to some degree 
if the latter were fixed to the uterine wall. The fact of 
the latero-fioxion being to the rights supports the above 
method of accounting for the flexion^ as the umbilical 
vessels were to the left side of the middle line. The spina 
bifida occulta and the meningocele were possibly secon- 
dary to the retroflexion, but were more probably part 
of an original incomplete development of the central 
nervous system usually found in combination with mal- 
development of the alimentary tract and its processes. In 
the present specimen the mal-development of the processes 
was confined to the part of the allantoic stalk (according 
to His) which goes to form the umbilical cord. This latter 
alternative is the more likely since the flexion in this case 
is most marked where the vertebrse are most deficiently 
developed; and this is not the part of the vertebral 
column opposite to the point of attachment of the foetus 
to the uterine wall, but is in the cervical region. The mal- 
development of the spine was therefore most likely 
primary, and determined the site of the flexion of the 
spine, which had to bend backward somewhere, and did 
so in its weakest part. The retroflexion was therefore 
secondary. 

It is worth noticing that there was no persistent vitel- 
line duct, as Ahlfeld believes that this foetal relic causes 
the combination of ectopia viscerum and retroflexion by 
dragging the gut out of the abdomen, and thus pulling 
the centre of the spine to the front. 

Abthub E. Giles. 

W. Dakin. 

Lbith Napier. 



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307 



PRIMARY CARCINOMA OF THK FALLOPIAN 

TUBE. 

By C. J. CULLINQWOBTE, M.D. 

Dr. Cullinoworth exhibited a spirit preparation from 
St. Thomas's Hospital Museum of primary carcinoma of the 
right Fallopian tube, with secondary infection of the broad 
ligament, and of the exterior of an ordinary adeno- 
matous cyst of the corresponding ovary. The specimen 
was removed by abdominal section on July 21st, 1892, 
from a married woman named E. G — , residing at Ewell, 
near Epsom. The patient's age was sixty. Her mother 
was said to have died of cancer in the chest at the age 
of sixty-three. Her own history was as follows : — The 
catameuia appeared at the age of fifteen, and were regu- 
lar up to the age of forty-eight, when she had an illness 
said to have been consequent upon a chill received during 
menstruation. She was confined to bed for several 
weeks, and leeches and poultices were applied to the 
lower part of the abdomen. The catamenia ceased for a 
time, but afterwards recurred regularly as before until 
the age of fifty-one or fifty-two, when they finally ceased. 
She was married in 1853, but had never become pregnant. 
Her husband, a healthy stonemason, was still living. At 
the menopause the patient had an attack of jaundice, and 
was ill for two months, six weeks of that time being 
spent entirely in bed. 

She dated her present illness from an attack of severe 
paroxysmal pain in the right iliac region, which occurred 
suddenly, in March, 1892, whilst she was going upstairs. 
The pain lasted a week, and gradually spread over the^ 
whole abdomen. There was absolute constipation 
for twenty days, when a natural motion was passed. 
After some weeks in bed she recovered, but had a re- 
lapse about the end of April, and had been in more or 



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808 PBIMABY CABGINOMA OF TEE FALLOPIAN TUBE. 

less pain ever since. About three weeks before admis- 
sion (July 16tli) she noticed that her abdomen had 
become enlarged, and that there was a hard lamp to be 
felt low down. It was thought an abscess was in course 
of formation, and leeches and poultices were ordered to 
be applied. The lump had continued to g^ow; there had 
been gradual loss of flesh, dating from the attack in 
March, but, notwithstanding this, the patient on admis- 
sion was healthy-looking and fairly well nourished. Her 
tongue was clean, her temperature normal, her urine 
free from albumen or sugar, and of specific gravity 1015. 
The chest signs were all healthy, the abdomen was some- 
what distended, chiefly in the flanks and at the lower 
part. There was a hard, nodulated tumour in the 
hypogastric region with a well-defined margin, 4^ inches 
from the anterior superior spine of each ilium. There 
were two hard nodules to the right of this, very super- 
ficial and apparently unconnected with the main mass. 
The front of the abdomen was for the most part resonant 
on percussion ; there was dulness from the pubes upwards 
to a distance of about 4^ inches, and also in th^ flanks, 
the note in the latter situation changing with the posi- 
tion of the patient. The girth at the umbilicus was 
33^ inches ; the other measurements elicited nothing of 
special interest. 

Abdominal section was performed on July 21st, 1892. 
There was a quantity of free fluid in the peritoneal cavity. 
The right ovary was the seat of a large cystic tumour 
adherent to neighbouring parts. The walls of the tumour 
were thin, but contained in places on their external sur- 
face numerous nodules of solid growth. The cyst 
contained about six pints of dark brown fluid. In front 
of the ovarian tumour and attached to it lay a hard, 
inflexible, elongated tumour about 3^ inches long and an 
inch in diameter, consisting of the right Fallopian tube 
infiltrated with new growth. The diseased tube and 
ovary were removed by tying and dividing the broad 
ligament in the usual manner. The divided tissues were 



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PBIMABY CARCINOllA OF THE FALLOPIAN TUBE. 309 

thickened^ probably from extension of the growth. The 
ovarian cyst was raptured daring removal^ some of its 
flaid contents escaping into the peritoneal cavity. The 
nteras was apparently nnaffected by the disease. The 
pelvic glands were felt to be enlarged and indnrated. 
A band of omentum was adherent to the anterior 
abdominal wall just below the lower angle of the incision. 
In the omentum at the site of the adhesion was a hard 
mass of new growth about an inch long and half an inch 
broad. An attempt was about to be made to remove the 
nodule^when it was noticed that it had attached itself to and 
implicated the wall of the bladder. The right kidney 
was felt to be enlarged and fixed. The pelvic cavity was 
well irrigated (on account of the contents of the cyst 
having escaped)^ and the abdomen was closed without 
drainage. 

The patient recovered well from the operation, the 
temperature on no occasion reaching 100^ F. She was 
discharged on the twenty-third day with a good appetite, 
and feeling greatly relieved. 

Exactly six months from the day on which she left the 
hospital, viz. on February 13th, 1893, she came complain- 
ing of symptoms that suggested threatened intestinal 
obstruction. She had been fairly well in the meantime, 
able to get about, and comparatively comfortable aud free 
from pain, but since Christmas had been obliged to take 
aperients which caused her much pain. She looked well, 
and had lost very little flesh. There was at that time 
no re-accumulation of fluid. A lump could be felt above 
the umbilicus. For her subsequent history I am in- 
debted to the kindness of her medical attendant, Dr. 
Daniel of Epsom, who writes as follows: — "Within a 
few months of [Mrs. G.'s] death, the dull aching with 
occasional shooting pain recommenced. The whole region 
of the uterus became a large, hard, and irregularly 
globular mass, firmly adherent on the right side, but with 
slight movement on the left, and a large portion of the 
vagina was involved. The whole abdomen became 

VOL. XXXVI. 22 



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810 PBIKABT CABCIHOKA OV THE FALLOPIAN TUBE. 

enorinonsly distended, and there were occasional attacks 
of local peritonitis, some ascites, distension of veins, and 
OBdema of the legs. Constipation increased, vesical 
troubles supervened, and the patient became unable to 
take food. For a few weeks previous to her death she 
was kept under the influence of opium or morphia.^' She 
died from exhaustion on July 11th, 1898, ten days short 
of a year from the date of the operation. There was no 
post-mortem examination. 

The following description of the parts removed (see 
Plate Y) has been furnished by Mr. Shattock, curator of 
the St. Thomas's Hospital Museum. '* The tube is trans- 
formed into a resistant, somewhat tortuous, coarsely nodu- 
lated, cylindrical mass, about 8 cm. (3 inches) long, which, 
on incision, presents an irregular cavity about 2 cm. in 
maximum diameter, with ragged, broken-down interior. 

''The ovary is the seat of a large multilocularcyst, measur- 
ing in its collapsed state 6 inches x 4 inches. The interior 
of this offers no unusual appearance, but on the peritoneal 
aspect there are numerous small hemispherical elevations 
of new growth, which in places form a coarsely granular 
confluent layer, indicating peritoneal infection, arising 
probably from the interior of the tube, on the outer surface 
of which there occur similar elevations. The fimbriated 
end of the tube, however, appears at present to be closed. 

" Histology. — Longitudinal sections carried through the 
entire thickness of the wall of the diseased tube show an 
infiltrating growth, having characters closely resembling 
a duct carcinoma of the breast. Close up to the external 
surface, the walls of the tube (which at the part examined 
are about a quarter of an inch in thickness) are riddled 
with spaces lined with columnar epithelium ; the spaces 
have mostly so wide a lumen that they may be designated 
cystic, and into them there project papillary processes 
invested with similar epithelium. 

" The histology of a prominent solid projection of new 
growth, about the size of a filbert, in the neighbourhood 



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DESCRIPTION OF PLATE V, 

Illustrating Dr. CuUingworth's Specimen of Primary 
Carcinoma of the Fallopian Tabe. 

Fio. 1 shows the cancerous tube laid open. The ragged, irregular 
cavity ia well seen, with its walls thickened hy cancerous infiltra- 
tion. A portion of the ovarian cyst has heen retained to show the 
intimate connection between it and the posterior surface of the 
diseased tube. 

A,. Divided surface of diseased tube. 

B. Irregular interior of same. 

o. Outer surface of the ovarian cyst against which the tube lay 
and to which it was attached. 

D. Closed cavity, probably a part of the canal of the tube isolated 
from the rest. 

Fig. 2 shows a portion of the external surface of the ovarian cyst, 
upon which is seen a cluster of hemispherical elevations of (second- 
ary) new growth, surrounded by scattered nodules of a similar 
character. The interior of the cyst was unaffected. 



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Finite V 



Fiq.l. 



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PmKABY CABCINOMA OF THE FALLOPIAN TUBS. 311 

of the tabe is for the most part precisely similar. But the 
section presents areas of younger date^ in which the fibroas 
matrix is occapied with groups of small solid cylindrical 
epithelial processes ; these^ as they grow, acquire a lumen 
of increasing dimensions, until a microscopically cystic 
character arises, and intra-cystic papillary formation 
ensues. 

''The section offers an additional and noteworthy appear- 
ance, and one not easy at first to interpret. 

*'The lumen of certain of the epithelial spaces is occupied 
by fibrous tissue. That it is the lumen of a tubule that 
is in question, and not the core of a papillary process, is 
clear from the fact that there is but a single investment 
of epithelium ; i. e. there is no reflection of epithelium 
from the surface of what might be regarded as a papillary 
process to the interior of any containing space. Some 
of the lumina are filled with blood-clot, in which an 
abnormally large number of cell-elements is present ; 
and it is to the organisation of blood shed into the tubules 
that I should attribute the existence of the connective 
tissue. Theblood, inshort, is organised by the ingrowth 
of granulation tissue from the connective tissue lying 
beyond the epithelium, much as takes place in the 
organisation of the thrombus in an artery that has been 
ligatured ; or the process may be more aptly compared 
to the organisation of inflammatory lymph filling the air- 
vesicles in croupous pneumonia.'^ 



Mr. Alban Doban stated that in Dr. Cullingworth's case 
the patient was older than in any other already recorded. 
Seven instances of primary carcinoma had been reported in a 
satisfactory manner. In five the new growth had developed in 
an apparently normal tube (Martin, Zweifel, Tuffier, Wester- 
mark; and Dr. Amand Bouth's case, where Mr. Thornton 
operated, and Mr. Doran reported the appearances in the 
'Trans. Path. Soc.,' vols, xxxix and xl). There was bloody 
discharge or menorrhagia in all these cases. In two (Drs. 
Essex Wynter and Rentier) there was a cjat, into which the 
ostium opened ; the new growth extended from the tube into 
this cyst, which was probably a malformation of the kind 



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812 OVABIAN TUMOUR COMPLICATING PRBGNANCT. 

described by Zedel, and not a tubo-ovarian cjst. Ealtenbach's 
case, wbicb he at first desciibed as primary carcinoma of the 
tube, appeared on further examination to l>e a papilloma. Of 
primary sarcoma of the tnbe little was known. Landan's case 
was well reported. Senger of Breslau, and Charles Dixon-Jones 
of Brooklyn had described four, but all were based on post- 
mortem examinations alone, and it was suspected that, at least 
in Senger* s tube, the deposit was inflammatory, not sarco- 
matous. There could be no doubt about treatment. When- 
ever a tumour developed on one side of the uterus in a woman 
about fifty, with sanious discharge, that tumour should be 
removed as soon as possible, as it may possibly be cancer of the 
tube. At the operation cancer cannot always be distinguished 
from papilloma. The tube must be removed close to the 
uterus. Dr. Cullingworth's case had lived for a full year. 
Should the disease prove to be papilloma recovery might be 
complete. Dr. Cullingworth must be commended for publish- 
ing his case in full, duly waiting for the after history. 



OVARIAN TUMOUR COMPLICATING PREGNANCY 
—CYST RUPTURED DURING EXAMINATION 
—IMMEDIATE LAPAROTOMY— RECOVERY. 

By William Duncan, M.D. 

The patient, C. H — , a multipara aged 30, applied at the 
Chelsea Hospital for Women on October 5th, 1894, 
complaining of a bearing- down pelvic pain and a yellow 
discharge. Has had several miscarriages during the 
last year ; the last one happened four months ago. The 
patient was examined at 4.30 p.m. by the resident 
medical officer, who found a cyst about the size of a large 
cocoa-nut, filling up the pelvis and pushing the enlarged 
uterus upwards and to the left. The patient was now 
examined by a clinical assistant, and during his examina- 
tion he felt the cyst disappear suddenly, and the patient 
was seized with severe abdominal pain and collapse. She 
was at once admitted, and Dr. Duncan sent for. On hia 



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SARCOMA OF OVAET. 813 

he fonnd slight dalness in the flanks^ but nothing 

mal in the pelvis. He performed abdominal sec- 

at 6 p.m. On opening the abdomen a lot of clear 

^us flaid escaped : the nterus was seen to be enlarged 

abont the size of a large orange (and thought to be 

ravid) ; the left appendages were found to be normal^ 

but the right ovary was the seat of a cyst which had 

ruptured^ so it was removed in the ordinary way. The 

fluid in the peritoneal cavity was sponged out and the 

abdomen closed ; no flushing or drainage was resorted to. 

The patient made an uninterrupted recovery^ except that 

she miscarried on the fourth day. 

Dr. Duncan said the case illustrated the importance of 
great care and gentleness in palpating a pelvic cyst^ 
especially as in some cases of pyosaJpinx the cyst wall is 
in places very thin. 

In answer to Dr. CuUingworth's question he said the 
amount of fluid in the abdomen was about a pint. 



SARCOMA OP OVARY. 

By W. R. Daeik, M.D. 

Dr. Dakin showed a solid tumour of the right ovary 
which he had removed from a woman aged 26^ a 3-para. 
She had noticed that her abdomen was increasing 
in size for nine mouths, and three months before that 
she thought she felt a moveable lump there. There was 
a moderate loss of fleshy not more than is found in the 
case of many ordinary multilocular cysts, and she had 
had little or no pain. Menstruation had not been 
affected. On examination the tumour felt so like a cyst 
that its solid nature was not suspected ; and there was no 
ascites. She had a trace of albumen in the urine. 



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814 8ABG0MA OF OYAST. 

At tbe operation it was found that the . 
longed to the right ovary and was solid. There were OBt^ 
two adhesions^ both to the omentum ; and as these were 
extensive^ a fair quantity of omentum was ligatured and 
removed with the mass. There was little or no excess of 
peritoneal flaid. The patient made an uninterrupted re- 
covery^ and indeed began to pick up flesh at the end of a 
week after the operation. The left ovary was found to 
be normal in feel and appearance^ and was left behind. 

The tumour weighed 9 lb. 6 oz,, and was homogeneous 
in structure to the naked eye after section. It measured 
11 inches by 8 inches by 8 inches. It proved to be a 
mixed spindle- and round-celled sarcoma^ and sections 
taken from different parts of the growth were alike in 
structure. 

Some of the sections were shown. 

The operation was performed a month ago, and Dr. 
Dakin proposed to report the after history of the case. 

Dr. CuLLiNowoBTH mentioned the case of a girl of nineteen, 
from whom he removed on April 1st, 1891 (three and a half 
years ago), a solid ovarian tumour 4 inches by 5 inches, which 
was pronounced by Mr. Shattock, after repeated examinations, 
to be an undoubted example of a spindle-celled sarcoma. The 
only symptom of ill-health in this case was menorrbagia, and 
the existence of the tumour was discovered, as it were, acci- 
dentally during a vaginal examination. The tumour was non- 
adherent. The opposite ovary wa& quite healthy, but was 
removed on account of the suspicious nature of the growth in 
its fellow. The girl made an excellent recovery, and up to the 
present time had had no recurrence. She was able to do her 
work as a domestic servant, and was now living at the house of 
a well-known surgeon in Harlej Street. She continued to 
report herself at intervals. Such a result was highly encourag- 
ing, and he trusted Dr. Dakin would be able to give an equally 
satisfactory account of his patient. 



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315 



CONCEALED ACCIDENTAL BLEMORRHAGE — 
PCETUS, PLACENTA, AND MEMBRANES 
DELIVERED ENTIRE. 

By W. R. Dakin, M.D. 

Dr. Dakin showed a seven and a half months^ f cetus bom 
in its membranes, which were attached to the placenta. 

The patient had had five abortions at the third and 
foarth months, and two children at term ; the latter of 
which, being the result of the last preceding pregnancy, was 
bom sixteen months ago. There was no history of 
syphilis. About six weeks before she expected her con- 
finement she received some news which shocked her very 
much, and three days after this she suddenly began to 
have intense abdominal pain, which was constant and 
not intermittent. The uterus was found to be very 
tense, and tender to the touch, and the os showed no 
sign of dilating. She remained in this condition for 
fourteen to sixteen hours, when labour began with a gush 
of blood from the vagina. Two hours after this the 
foetus enclosed in its membranes as described was born, 
and the ovum was immediately followed by a quart of 
firmly clotted blood, representing about three pints of 
fresh blood. There had been no fcetal movements and 
no foetal heart to be heard for two days before labour 
began. The quantity of liquor amnii, though perhaps 
somewhat under the full amount, was not markedly less 
than normal. The child, by measurement and by its 
degree of development, was found to correspond to the 
date named. The placenta was healthy. 

There was no history of a fall or a blow, and the 
concealed accidental hasmorrhage was either the cause 
or effect of complete detachment of the placenta. Dr. 
Bell, of Leytonstone, had kindly sent up the specimen to 
8t« George's Hospital. 



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316 

EUPTURED UTERUS. 
By G. F. Blacme, M.D., F.R.C.S. 

The patient, aged 33, had liad six children previonsly, 
all delivered with forceps under chloroform, with g^eat 
difficulty. 

Labour commenced at 8 a.m. j the membranes ruptured 
at 10 p.m., medical assistance being sent for at mid- 
night. 

At this time the patient's general condition was found 
to be good. Pulse 96. Pains infrequent and rather 
feeble. 

The head was lying transversely, occiput to left, par- 
tially engaged. Diagonal conjugate estimated to be 
8^ inches. 

Quinine sulphate, 8 g^s., was given to induce more 
marked pains, with no result. 

Chloroform was then administered, and forceps applied. 

Before traction was made a hypodermic injection of 
citrate of ergotinine, yoDT ST'> ^^^ given. 

Traction was then made, but the forceps slipped. They 
were reapplied with the same result. 

After the third application the cord was found pro- 
lapsed and pulseless. When Dr. Blacker saw the patient at 
6 a.m. forceps had been applied some six times, with the 
result that they slipped each time. 

The patient had been under chloroform two hours; 
was exceedingly collapsed ; pulse 122, small, and at 
times irregular. 

The uterus was quite lax. There was no ring of Bandl. 
The parts of the child were easily felt, and pains were 
very infrequent and feeble. 

Perforation and delivery with the craniotractor was 
easily effected. 

On subsequent introduction of the hand a tear in the 



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KUPTURBD UTERUS. 



817 



left side of the cervix^ passing into the left broad liga- 
ment^ was discovered^ the hand passing into a ragged 
cavity to the left of the uterus. There was no external 
hsBmorrhage^ nor had there been any previous to delivery. 
A strong iodine douche was given, and the patient re- 
moved to University College Hospital, close by. 

On admission she was very markedly collapsed, com- 
plaining of some pain in the left iliac fossa. 

Pulse 112, very small and feeble. Respiration 44. 

There was slight deficiency on percussion in both flanks. 
She improved a little under the administration of brandy. 

During the time she lived she had several attacks of 
intense pain in the abdomen and precordial region, 
accompanied with great respiratory distress and cyanosis. 
She finally died ten hours after delivery, immediately 
after the termination of one of these attacks of pain. 

At no time after admission did her condition improve 
sufficiently to allow of any operative interference. 

At the autopsy 1^ pints of blood were found in the 
peritoneal cavity. 

The uterus was found to contain a tear 3 inches in length, 
passing through the left side of the cervix, and extend- 
ing from the internal os to the vagina, communicating 
with a large ragged cavity in the left broad ligament. 
The latter was almost entirely torn away from the uterus, 
remaining attached only by the Fallopian tube, round 
ligament, ovarian ligament, and upper part of the broad 
ligament. 

There was a subperitoneal hsBmatoma reaching up to 
within 1^ inches of the lower end of the left kidney. 

Three inches from the fundus in the anterior surface 
of the uterus was an incomplete rupture, involving the 
muscular fibres and the peritoneal coat only ; and there 
were three smaller similar ruptures near the fundus. 

The other organs were all healthy. 

The child weighed 8 lbs. 10 oz., and measured 22 
inches in length. 

The diameters of the pelvic brim were as follows : — 



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318 UTERINE FIBROID. 

Conjugate^ 3^ inches ; transverse 5^ inches ; right obliqne, 
5^ inches ; left obliqae^ 5 inches. 

The President said the Society was much indebted to Dr. 
Blacker for this interesting specimen, but more especially for 
the very full clinical history of the case which he had given, 
including, as it did, exact information as to the size of the 
pelvis and that of the child — poiuts of the first importance, but 
yet often omitted in the reports of similar cases. 



UTERINE FIBROID. 
By J. H. Galton, M.D. 

Dr. Galton showed a specimen of uterine fibroid 
removed by enucleation after abdominal section^ and the 
ovaries (one cystic) from the same case. 

The case occurred in the Norwood Cottage Hospital^ in 
a patient aged forty-two. A tumour filled the pelvis, pro- 
jecting above into right iliac and hypogastric region. It 
could not be lifted out of the pelvis, and the os uteri was 
drawn upwards and forwards. The uterine sound passed 3 
inches intoapyriform projection which could be felt in front 
of the tumour, and the uterus was moveable independently 
of the tumour. Dr. Horrocks saw the case and advised 
exploratory incision, which was made on November 5th, 
disclosing uterus and ovaries in front, tumour behind 
covered with peritoneum, which had been lifted up by 
growth backwards of the tumour from Douglas's pouch and 
the floor of the pelvis, so that the tumour was sessile and 
filled the whole pelvis. A trocar failed to find fluid to 
lessen its bulk, and the bleeding from the wound com- 
pelled completion of the operation, as had occurred in two 
previous cases which he had seen. The broad ligament 
was transfixed on either side, and tied on each side of 



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(7TBRIKE FIBROID. 819 

ea«h ovary^ and the ovaries removed. An incision 
starting from the trocar woand was made through the 
peritoneum^ and the tumour enucleated by the fingers^ 
leaving a broad pedicle of attachment to the back of the 
uterus. This was tied, but the uterine ligature slipped 
off and disclosed an open wound into the back of uteras 
through which a sound passed. This wound was closed 
by four silk sutures. There was but little hasmorrhage, 
and the abdomen was not washed out, owing to fear of 
subperitoneal infiltration. No drainage was used. The 
abdominal wound (which had been enlarged to 4 inches to 
admit removal of tumour) was closed by five silver wire 
deep sutures and the usual dressings applied. The opera- 
tion lasted one hour and twenty minutes. The tumour 
weighed 1 lb. 10 oz. The patient was greatly collapsed 
during operation, but slowly recovered, and at present 
time, fifty-eight hours after, her pulse was 80 to 99*2 ; 
resp. 20. Urine was passed naturally, and she had 
abdominal respiration ; was free from pain, although 
she had not taken any opiate since the operation. 

Dr. Pbtbb Hobbocks said be had seen the patient before 
operation, and owing to the absence of menorrbagia and the 
smallness of the uterus he had looked upon the tumour as more 
probably ovarian rather than uterine in origin. At the same 
time he had advised abdomioal exploration on account of the 
pressure symptoms caused by the tumour. He thought it 
would have been better to have punctured the tumour with a 
small needle such as the subcutaneous syringe, in order to deter- 
mine the presence or absence of fluid, instead of usin^ a large 
trocar and cannula, which caused profuse hsBmorrahge in many 
solid tumours, and necessitated further operative procedures. 

Dr. BoxALL briefly mentioned a case which presented very 
similar characters, but the mass had sprung from the vaginal 
cervix. The case, both in physical characters and symptoms, 
pointed to the probability of retroversion of the gravid uterus. 
In that case the mass was dealt with from below. The body 
of the uterus was displaced forwards and upwards above the 
symphysis, and was not enlarged. 

Dr. HsTwooD Smith suggested, with regard to what had 
been said in favour of exploring such tumours with a trocar, 
that it would be better to proceed with the operation without 



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820 UTBBINE FIBROID, 

piinctaring, as the tumour bad to be remoTed, and in tbe case 
of solid tumour it migbt give rise to troublesome bsBmor- 
rbage ; and should it be cystic, it would, if there was so much 
doubt as to its contents on being handled, most probably have 
such thick walls as not tobe materially reduced in bulk, and some 
contents deleterious to the peritoneum might escape. He con- 
sidered, therefore, that such proceeding should be omitted, as 
inyolving waste of time productive of no good. 

In reply, Dr. Q-alton thought that the tumour grew from the 
uterus higher up than the supra-vaginal cervix, and the tear in 
the posterior wall opened into the uterine cavity. He supported 
the use of the trocar as likely, if fluid were found, to obviate the 
necessity of enlarging the abdominal incision. He thought 
that owing to the conditions of growth in this case, and the 
binding down of the tumour, notMng offered a chance of relief 
but removal. 



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321 



A NEW AND SPEEDY METHOD OP DILATING 
A RIGID OS IN PARTURITION. 

By Joseph Fabbab, M.D. 

The new method which I beg to bring before the^ 
Society, and which I may at once confess to have 
discovered by accident, is as simple as it is effectual, and 
as painless to the patient as it is speedy and free from 
danger. 

How frequently has the accoucheur to ^lament the 
meeting with a rigid, unyielding os uteri, when the 
boundary of the orifice is as if made of tin-plate, and 
almost as sharp to the finger as the edge of a knife ! In 
some of these cases the attempts at stretching with the 
finger, or with a mechanical dilator, or by means of the 
india-rubber bags, are very disappointing ; and if success- 
ful are nearly always tedious, and therefore more or less un» 
satisfactory, besides being painful, wearisome, and propor- 
tionately trying to the patient. Occasionally, too, each and 
all of these methods fail, one after the other ; and then 
we have recourse to incisions of the boundary of the 
orifice, with consequent danger of septicmmia, and the 
tearing of the uterus upwards during a strong pain. 
Any other means, therefore, of accomplishing our object, 
and of fulfilling the conditions I have just put forward, 
will be warmly welcomed, not only by the poor suffering 
patient, but by the anxious and worn-out practitioner 
as well. 

About four months ago I had one of these tedious cases 
to deal with. The patient was a primipara, and I had 
been in attendance, on and off, for some forty-eight hours. 
I had given chloral, combined, as recommended by certain 



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322 A NEW AND SPEEDY METHOD OF DILATING 

of the profession, with the bromide of potassium ; also 
morphia, followed by most persevering attempts at digital 
and mechanical dilatation, with and without chloroform, 
but with absolutely no appreciable result. The patient 
heing nearly worn out with violent and involuntary bear- 
ing-down pains, I decided to incise the margfin, previously 
rendering the parts anaasthetic by the local application of 
•cocaine. I used a 10 per cent, solution, applying it by 
means of a piece of linen rag, smearing it round and 
round on the end of the finger, and leaving it ther6 for 
three or four minutes. Judge of my surprise and 
greater satisfaction on introducing the left index finger 
as a guide to the point of the scissors, to find the 
previously rigid os widely dilated, and as distensible as a 
rubber bag I The dilatation took place, as I said, in three 
or four minutes ; and I could not help coming to the con- 
clusion that mere coincidence was quite out of the qnestion. 
The changed condition of matters was so sudden, and alto- 
gether so diSerentfrom anything in my previous experience 
in such cases, that I could come to no other conclusion than 
that it was the cocaine which caused this rapid change. 

However, before calling the attention of the profession 
to the matter I determined to wait for another, and if 
possible, a more severe case, to act as a kind of control 
experiment. The opportunity presented itself two months 
afterwards in a primipara of over forty years of age. The 
OS, as in the case just mentioned^ failed to yield either 
from internal medication or by direct digital or mechan- 
ical means. I waited three days, to give the case every 
chance of a natural termination ; and then, all means 
failing, I applied the cocaine — ^not^ I confess, without 
a certain feeling of anxiety as to the result. I had 
not long to wait, for, as in the first case, and in four 
minutes' time, the os yielded, and was so distensible that 
I was soon able to slip it over the child's head, and in 
due course to complete the delivery. 

Both these cases were so striking in the results that 
I could hesitate no longer to bring the facts before the 



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A EIGID 08 IN PABTUBITION. 823 

profession^ and to advise a trial of cocaine in cases of 
persistent rigid 08 arising from physiological causes. 

Dr. Amand Eouth thought Dr. Earrar's paper a very valu- 
able one, but did not think his use of cocaine was quite new. 
In the 'British Medical Journal ' for September 6tb, 1885, Dr. 
Dabbs, of Shanklin, had drawn attention to its use as relieving 
the pains of the first stage of labour, and in the same journal, 
on December 12th, 1885, Dr. Head Moore, commentiug upon 
this, advised the use of cocaine and boric acid pessaries, which 
would, he believed, " prove of use in the first stage of labour, 
especially in primipara and in cases of rigid os." Dr. Bouth had 
made several trials of these " Head Moore cones," as advised, 
and found them so useful that he recommended them to a post- 
graduate class at Charing Cross Hospital in 1888, stating at 
the same time that he was uncertain whether the result was not 
due as much to the glycerine (in Dr. Dabbs' solution) and to 
the oleum theobromsB in Dr. Head Moore's cones) by encourag- 
ing the cervix to secrete, for it is well known that a secreting 
cervix is a dilatable one. 

Dr. Lbith Napibb considered that if extended experience 
corroborated Dr. Farrar's observation a most valuable addition 
to our resources in treating rigid cervix would be found. The 
usual effect of chloroform narcoses in this condition was well 
known. Dr. Leith Napier had formerly frequently employed a 
20 per cent solution of cocaine as an intra- vaginal application 
prior to gynsecological examinations and minor operations, but 
he had found this solution, which was twice the strength of 
that used by Dr. Farrar in his two parturient cases, most 
ineffective. While of course accepting the clinical facts adduced, 
it was very difficult to find a satisfactory explanation. A much 
larger number of cases and some intelligible therapeutic explana- 
tion would be very desirable. 

Dr. Pbtbb Hobbooks thought that if this communication led 
to the establishment of the efficacy of cocaine in a rigid os, 
great credit would be due to Dr. Farrar. He did not think 
that the effect of chloroform upon muscular fibres, particularly 
of the involuntary type, was known. The relaxation of the 
sphincter ani, which was a voluntary muscle, often indicated pro- 
found ansBsthesia, and hence it was a signal of danger. And 
yet even when this had occurred a rigid os remained rigid still. 
Hence he considered that chloroform was not a suitable remedy 
for rigid os, and that a patient would die before such an 
involuntary muscle had relaxed owing to the chloroform. He 
mentioned that painting the surface of the vulva or vagina with 
a 20 per cent, solution of cocaine was not nearly so good a local 
ansBsthetic as the injection of a 5 per cent, solution under the 



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324 NEW METHOD OF DILATDIG A RIGID OS. 

integumonts, and he suggested that possibly injection of a weak 
solution of cocaine into the substance of the cervix might prove 
more efficacious than the mere application of a stronger solution 
to the surface. 

The President said that many obstetricians had tried to 
make cocaine useful for lessening the pain of labour, and if 
cocaine had any regular effect in accelerating a normal first 
stage of labour, it was strange that it should not have been 
noticed. It was very difficult to draw a clear distinction 
between mere slow dilatation of the cervix, the labour being 
normal in every respect except speed, and dilatation arrested by 
some abnormal spasmodic contraction of the cervix, if such a 
thing existed. It was quite conceivable that a drug might 
have no effect on a normally, though slowly, progressing 
labour, and yet be able to remove the hindrance caused by a 
spasmodic contraction of the cervix. In Dr. Farrar's cases it 
seemed as if there were something more than mere slowness of 
normal dilatation, for in one the condition was stationaiy for 
forty-eight hours, and in the other for three days, and the 
dilatation occurred with wonderful rapidity. Two cases were a 
slender foundation on which to base a therapeutic statement, 
but Dr. Farrar's two cases were very remarkable ones, and if 
his statement based on them were confirmed by further experi- 
ence he would have made a valuable addition to oui* obstetric 
resources. 

Dr. Fabrab, in replying, said he felt much honoured that his 
paper had elicited so much discussion. He did not, however, 
take credit to himself for his discovery, seeing it was the result 
of pure accident. One gentleman had asked for some explana- 
tion as to how the drug could act in the manner claimed, but 
this .Dr. Farrar said he did not pretend te know, and that he 
was therefore quite unable to give the information. What he 
was able to say was that it did act in the manner he had 
stated, and that it would take a great deal of argument to con- 
vince him to the contrary. In answering the President, who had 
asked what size the os was in each of the cases previous to 
applying the cocaine, Dr. Farrar said about the size of a shilling 
piece. Finally, he begged the Fellows to try it in such cases as 
he had indicated, as he himself would certainly do ; and he pro- 
mised that if in future trials it should prove a failure, he would 
duly inform them of the circumstance. 



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325 



ON ATROPHY WITH COLLAPSE (CIRRHOSIS), 
FIBROID DEGENERATION, AND ANGIOMA OF 
THE OVARIES. 

By James Buaithwaite, M.D.Lond., 

OBSTBTBIC PHYSICIAN AND SUBQEON TO THE LEEDS dBNEBAL INFIBMABY. 

(Received Aagast 8tb, 1894.) 

The following paper is founded chiefly upon one case, 
but the conclusions come to are illustrated by, and com- 
pared with, observations upon other two cases, in which 
the pathological condition was the same as that present 
in the first so far as regards the *^ cirrhosis/^ as it has 
been called. This " cirrhosis,*' which is really a collapse 
and atrophy of the outer portion of the ovarian stroma, 
being totally different from true cirrhosis, ought not to 
be called by the same name. A more appropriate name 
would be " Sumptoma '* {avjuLirTWfxa,^ collapse). 

This collapse and atrophy form the chief subject of 
this paper. Fibroid degeneration and angioma only come 
in incidentally because present in the ovaries in addition 
to the collapse. The conclusions come to upon the sub- 
jects which have been named, are such only as can be 
deduced from the pathological changes actually observ- 
able in the cases related, and the sections being on the 
table, the correctness or not of the observations can be 
judged of by the Fellow present. I make no reference 
to the somewhat scanty literature of the subject further 
than to say that the opinion of the profession upon it ia 
undecided, because it has not been thoroughly worked 
out. The puckering is supposed to be owing to fibrosis 
* Dion Ca^sius (fl. 180 a.d.) ases this word in his accoant of the ooUapser 
or falling in of the Fncine Lake. 

VOL. XXXVI. 23 



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326 ATROPHY WITH COLLAPSE. 

of the ovary occurring independentlj of inflanmiation. 
So that cirrhosis and fibrosis would, according to this 
idea, necessarily go together. It will, however, be shown 
that there is no connection whatever between them. I 
may here say that suiBScient attention has not been given 
to Wedl^s* brief allusion to the disease. He puts it 
rightly amongst atrophies, and speaks of it as an 
'* atrophy of the Graafian follicles.'* The case which 
first drew my attention to the subject was the following. 

A. P — , aged 44, unmarried^ is a thin, small, dark 
woman. She was a patient of Mr. Edward Atkinson's, 
of Leeds, with whom I saw her on November 18th, 1892. 
Her health was perfectly good until 1890, during which year 
she says that she had influenza four times. This enfeebled 
her a good deal, and about Christmas of that year she first 
noticed pain in both iliac regions. This soon increased 
sufficiently to be a great annoyance to her, and it was 
her principal complaint at the time I saw her. She 
described it as an " aching, always there," worse at the 
menstrual periods, but "bad'' between them. It was 
made worse by twisting the body sharply to one side, and 
especially to the left. In the morning, before getting up, 
she often noticed her body a little swollen, and there was 
a " dull aching and, occasionally, shooting pain." Each 
period lasted from three to ten days, and was rather pro- 
fuse. The intermenstrual intervals were very irregular, 
varying from fourteen days to six or seven weeks. Her 
appetite was not good, tongue clean, pulse poor and too 
quick. Her general aspect was not, however, suggestive 
of bad health, but she did not look strong. She had 
never been subject to neuroses, nor was she hysterical at 
all, but a matter-of-fact, pleasant, cheerful woman. There 
was no cause for the supervention of the pain except the 
one named, viz. influenza. Her circumstances and sur- 
roundings were fortunate and happy. 

Abdominal examination revealed only a little supra- 

• 'Wedl's Pathological Cystologes/ New Sydenham Society's edition, 
p. 169. 



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ATROPHY WITH COLLAPSE. 327 

pubic tenderness to deep pressure. Vaginal and bi- 
manual examination found the uterus normal as to position^ 
but the fundus was enlarged and suggestive of a small 
fibroid. There was, however, no irregularity of outline 
discoverable. The fundus was large, smooth, rounded, 
and very tender to pressure. The ovaries could not be 
distinctly made out. There was no pain elicited by 
examination and pressure where the ovaries should be 
found, and it was therefore certain that they were not 
enlarged or painful. On the other hand, pressure upon 
the uterus itself was unduly painful, and we concluded that 
although the pain complained of was in the iliac regions, 
its source must be in the uterus itself. She had already, 
before coming to Leeds, been subjected to a good deal of 
medicinal and general treatment, and nothing had done the 
least good. As she urgently asked for relief we decided 
to make an exploratory incision with a view to oophorec- 
tomy, especially as we thought it nearly certain that there 
was a small fibroid in the fundus. This I did at the end 
of November, 1892, Mr. Atkinson being present. 

The fundal end of the uterus was found decidedly 
enlarged, but its stony hardness was almost more notice- 
able than its enlargement. Even when it was between 
the fingers, however, I could not be certain that a fibroid 
existed. It seemed rather a general enlargement or 
fibroid thickening than an encapsuled tumour. 

The ovaries were brought into view without diJEculty, 
and their appearance, especially that of the left, was very 
remarkable. The left was very small and nearly as 
white as milk, with a crenated, puckered surface. The 
right was a little larger and the colour more normal. 
Both were removed with their tubes. No unfavorable 
symptoms of any kind occurred, and the patient made a 
good recovery. Menstruation never occurred again. The 
old pain was felt in a modified form for at least eight 
months, but it then absolutely disappeared. I saw her 
recently, and she assured me that she is now per- 
fectly well. 



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328 ATBOFHT WITH COLLAPSE. 

I have not since the operation had the opportunity 
of examining the condition of the uterus^ and indeed 
the patient would not now submit to an examination; 
but as the point of the case to which I wish to draw 
attention is the condition of the ovaries^ this absence of 
evidence about the present condition of the uterus is not 
important. 

The left ovary was in an advanced state of what would 
be called cirrhosis. 

The right ovary was a little larger, its colour was more 
normal. Its surface was nearly convoluted, but not quite 
so much as that of the left ovary. 

I gave half of this ovary to the Assistant Pathologist 
to the Yorkshire College (Mr. J. W. Haigh), and he 
reports that there was in his portion a very small ossifying 
fibroid tumour. This was not visible externally. 

In the section of the other half now shown the amount 
of normal stroma is seen to be much greater than in the 
left, and there is only one spot in which fibroid degenera- 
tion has commenced. This can be recognised by the 
naked eye by its lighter colour. The vascular supply of 
this ovary is good, and the walls of the vessels normal. 

There is seen to be a space or cavity in the centre of 
the section, just as in the left ovary, but it is not lined 
by remains of yellow tissue. There can, however, be no 
doubt that this was present in an earlier stage. This 
cavity, and pre-existing cavities as they shrank, have, I 
think, produced the puckering or convolution of the 
surface. 

In order to understand the question it is necessary to 
understand the natural history of a normal corpus luteum. 
The cavity of a normal corpus luteum contains a clot 
of blood, which in time becomes curiously glassy and 
transparent, but is still red in colour. As the yellow 
material increases in amount the clot shrinks, but there 
is never a considerable sized cavity or clear fluid in 
the interior. Ultimately the clot shrinks to a small 
size, the yellow material closing upon it. The corpus 



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ATROPHY WITH COLLAPSE. 329 

luteum of A. P — differs from the normal, first, in a 
marked deficiency, almost absence, of the yellow matter. 
Second, in the absence of the clot. Whether it ever 
existed or not I cannot say, but there is no trace of it, 
and the centre of the corpus contained instead clear fluid, 
and exceedingly fine fibrous or cellular tissue bordering 
the central space. Possibly the fibrous tissue may have 
completely filled it, and the central portion been lost in 
making the section, as it was extremely delicate. The 
clear fluid would be more or less held in the meshes of the 
fine fibrous tissue. 

In a corpus like this with its unsupported interior there 
must be a tendency to collapse. This collapse would be 
favoured by the small amount of normal ovarian stroma 
which forms the exterior of the ovary, and the same con- 
dition will be noticed in the two subsequent cases yet to 
be described. 

Before proceeding to other conclusions, which I think 
may be fairly come to from an examination of these 
ovaries, I will introduce a second case. 

On September 7th, 1893, I operated in the Leeds 
Infirmary upon a patient named Exley, suffering from 
what we supposed to be tubercular peritonitis. There 
turned out to be a tubercular mass involving omentum 
and bowel, and after letting out all the ascitic fluid, and 
inserting a drainage-tube, the abdominal wound was 
closed without any other operative proceeding except 
that I removed the right ovary. The left ovary was 
normal. Although it is not directly bearing on the 
subject, I may say that the patient made a good recovery, 
and bid fair to get quite well when we sent her home in 
October, 1893. This ovary, which for distinction I will 
call Exley^s ovary, had attached to it a cyst. This cyst 
has nothing to do with the subject in hand, but its exist- 
ence, along with the abnormal appearance of the ovary, 
was the cause of its removal. Exley's ovary, without the 
cyst, weighed only 47 grains, — a little less than A. P — 's. 



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880 ATROPHY WITH COLLAPSE. 

which was 53 grains^ and was markedly cirrhosed, but 
not of the white colour before described. The puckering 
of the external surface is more marked even than in 
A. P — *s ovary. 

As in A. P — 's left ovary the puckering of the surface, 
or infolding, as it might be called, is owing to collapse 
from sinking in at places where corpora lutea have ex- 
isted. This explanation of the weak central places which 
have allowed the collapse can be inferred from examination 
of this ovary, as it can from A. P — *s left ovary, although 
there is no trace of the yellow matter. What is actually 
seen in Exley^s ovary at the places in the centre which 
have allowed of collapse of the external surface is what 
is sometimes called myxomatous change or degeneration. 
Whether rightly or wrongly so called, 1 do not feel in a 
position to say. 

There is in the section of Exley^s ovary shown, fibroid 
degeneration of one small portion only, viz. an outlying 
piece connected to the rest by a neck. This degeneration, 
therefore, is quite out of the way of the collapsed portions. 
The type of degenerative fibroid bands is a little different 
in appearance from that seen in A. P — *s case. 

In Exley^s ovary there is no hyaline fibroid degeneration 
of the vessels. 

The next case is one of atrophy and collapse with what 
may be called angioma. 

Case 8. — ^H. G — , aged 37, was admitted into the 
Leeds Infirmary in December, 1893. Married some years. 
Never pregnant. Menstruation commenced at twelve, and 
there was dysmenorrhcea from the beginning. When 
admitted, she complained of pain in both iliac and sacral 
regions, and stated that this had existed for fifteen years, 
t. e. from the age of twenty-two, since which time she 
has always been an invalid. She was in the Chelsea Hos- 
pital for Women eight years ago, under the late Dr. Aveling, 
probably for retrofiexion, as various pessaries were used. 
Neither these nor any she has subsequently had, have 



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ATROPHY WITH COLLAPSE. 33J 

been of any benefit to the pain. The pain is worst during 
the menstrual period, which lasts three or four days, but 
she is not free from it during the intervals, which are from 
seventeen to nineteen days. During these intervals she 
occasionally, but rarely, has a little loss of blood. On 
vaginal examination there is found extreme retroversion 
with enlargement and tenderness of the uterus. The 
cervix points forwards and downwards, fundus backwards 
and to the left. The sound passes three inches. 

Before admission I had succeeded pretty well in keeping 
the uterus up with a Hodge pessary, but the. patient not 
being in the least relieved by this we admitted her for the 
operation of ventro-fixation of the uterus, with possible 
oophorectomy if anjrthing should be found in the ovaries 
to account for the pain. Bimanually the ovaries could be 
examined, but no enlargement was found, only extreme 
tenderness. 

The operation was done on December 9th, 1893, and 
the ovaries were found of a deep purple colour, and a 
trifle larger than usual. The colour was very remarkable. 
Both ovaries and tubes were removed, and the uterus 
then was fixed to the peritoneum just above the pubes by 
two silkworm-gut sutures. This was not easily done, as it 
could be pulled up to the abdominal walls with diJ£culty. 
The question being the pathological condition of the 
ovaries, I will not further allude to the progress of the 
case, except to state that she recovered well, and was 
examined on April 5th last, and again in July, when the 
uterus was found in good position. The patient was not 
free from pelvic pain, but was very much better and 
improving. 

The left ovary was found to consist of a mer 
true ovarian tissue, convoluted by collapse. Th 
portion of the ovary consisted of a convoluted 
small vessels larger than capiUaries, external 
there are spaces where corpora lutea have exii 
outside all, as stated, a thin shell of much-c< 
ovarian tissue. The right ovary consisted of c 



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882 ATEOPHY WITH COLLAPSE. 

corpus luteum with a large haBinorrhagic clot in the 
centre. The clot is separated from the corpus Intenm 
tissue hj a space nearly surrounding it. Attached to this 
is a mass of vessels as in the left ovary. 

This case^ I think, may be called angioma of the ovary 
with atrophy or collapse. 

In reflecting upon these cases we must remember that 
a certain amount of convolution of the surface of the 
ovary is normal. Even in the ovary of a virgin of sixteen 
or eighteen there is a little puckering of the surface. 
There is, however, remarkably little even in healthy 
multiparous ovaries, still there is some, and it is therefore 
only an excessive degree which is noticeable. This col- 
lapse in all three cases is associated, as I have before 
said, with atrophy, more or less, of the true ovarian 
stroma. 

In all the three cases there was a debilitating first 
cause. Influenza in the first, tuberculosis in the second^ 
and primitive dysmenorrhoea and subsequent incurable 
retroflexion in the third. The collapse of the surface is, 
therefore, not the primary disease, but is an effect or con- 
sequence of deficient and feeble reparative power. 

The fibroid degeneration, which was co-existent with 
the collapse, is evidently not the cause of it ; indeed, the 
surface at the parts where the fibrosis exists is rather 
convex and swollen. The outlying portion of Exley's 
ovary appears also to show that this change may even 
cause a small outgrowth. 

We may, however, surmise that the same debilitating 
causes which produce defective repair and collapse have 
hfhf^n in nnfiratinn to change the higher grade ovarian 

le fibrous tissue, 
lie deficiency in the amount of 
ovary is not the cause of the 
arked in Glover's ovary along 
>m excessive amount of blood, 
xtent, independent of the actual 



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ATROPHY WITH COLLAPSE. 333 

amount of blood, either in a woman as a whole, or in her 
ovary alone. 

On examining microscopically a healthy moltiparous 
ovary in old age it is found that there is a tendency, 
but only a tendency, to fibroid degeneration of the true 
ovarian stroma, but the greater part of it is the same 
as in health during the menstrual period of life. Fibroid 
degeneration of the ovary in middle age can hardly, there- 
fore, be called an early occurrence of the changes incidental 
to old age. 

This fibroid degeneration, also the hyaline fibroid de- 
generation of the vessels, and the angioma, may, however, 
be said to be exaggerated conditions of what may occur 
normally in a senile ovary. 

The number of vessels seen in the section of the pos- 
terior half of the senile ovary somewhat resembles what 
I have ventured to call angioma in Glover's ovary, and 
there is also hyaline fibroid thickening of some of the 



Although it is outside the subjects of this paper, as 
the section of the senile ovary is on the table, it is worth 
while noticing what a large amount of corpus luteum 
tissue there is in it, indicating by no means a simple 
passive existence. 

The Pbesident said that Dr. Braitbwaite's paper dealt with 
an important subject. Many cases bad been reported in which 
ovaries had been removed because they were painful ; and the 
cause of the pain was said to be that they were ** cirrhotic," — that 
18, small, puckered with few follicles and much fibrous tissue. 
Dr. Braithwaite's case differed from these only in being much 
more fully and carefully reported than the majority of them. 
Now, as to size, puckering, number of follicles, and amount of 
fibrous tissue, healthy ovaries varied very much. He (the 
President) knew of no observations as to the limits between 
which healthy ovaries might vary in size and weight. He knew 
of no criteria by which, if two small puckered ovaries, one taken 
from a patient on account of pain, the other from a patient who 
had no pain, were put side bv side on a plate, the ovary which 
was painful could be identified ; nor did he know any author 
who had attempted to describe any such criteria. 



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884 ATROPHY WITH COLLAPSE. 

Mr. Tabobtt said that he had recently examined a pair of 
oyaries in which the curious folding of the serous surface, re- 
sembling the convolutions of the brain, was even more marked 
than in the specimens shown bj Dr. Braithwaite. Microscopical 
examination revealed an advanced degree of chronic endarteritis 
not of a syphilitic type ; the lumen of the vessel in some in- 
stances was almost obliterated. Ho was of opinion that the 
glandular atrophy and fibroid degeneration in the organ might 
be due to the presence of this vascular lesion. 

Dr. Lbith Napijsb mentioned that there was a considerable 
amount of recent literatu]*e regarding the pathology of cirrhosis 
of the ovary. Stephen Bonnet and Paul Petit, in their work 
* Traits pratique de Gynecologic ' (Paris, 1894), had devoted con- 
siderable attention to it. Petit, Gusserow, Nagel, and others 
might be referred to as having made independent investigations 
on the subject. 

Mr. Malcolm said that the ovaries referred to by Mr. Targett 
were removed in the course of an ovariotomy, and not for pain. 
One of them was attached to a large ovarian cyst, but the form 
of the ovary was quite distinct except at its junction with the 
tumour. The other ovary showed an extreme degree of corru- 
gation of the surface. 



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335 



NOTE ON THE IMPORTANCE OP A DECIDUAL 
CAST AS EVIDENCE OP EXTRA-UTERINE 
GESTATION. 

By Waltbb S. A. Griffith, M.D. 

(Receiyed August 21 at, 1894.) 

E. J — J aged 25, married two years, no previous preg- 
nancy, husband living, admitted St. Bartholomew's Hos- 
pital July 30th, 1893. Pamily history nothing important. 
Previous health good. She is a stout, robust woman. 
Menstruation began at fourteen, always regular, duration 
three days, interval twenty-five days, quantity average. 
The last regular period ceased on April l7th, 1893. 
Fourteen days after, on May 2nd, there was a slight loss 
of blood; menstruation since absent (3^ months). She 
believed herself to be pregnant. The patient came to 
the hospital on July 30th, unable to pass her water, and 
complaining of a brownish discharge which had com- 
menced on the previous day. The urine was drawn oS, 
and a large uterine cast was found and removed from the 
vagina. No cause for the retention of urine was dis- 
covered. 

She was admitted into the hospital on the suspicion 
that she was suffering from extra-uterine pregnancy 
which had not yet ruptured. She had suffered from 
morning sickness lately, the breasts were said to be 
increasing in size and showed signs of activity. There 
was no history nor symptom of rupture of a gestation sac. 

The examination of the pelvic organs was difficult 
owing to her large size and the amount of fat in the 
abdominal walls; it was therefore made under an 



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836 IMPOKTANCE OP A DECIDUAL CAST AS 

anaesthetic. The uterus was a little enlarged^ roeasuring 
2| inches^ but no tumour was found in its neighbourhood. 
Description of the decidual cast, — The cast appears to 
be identical with those found in cases of extra-uterine 
gestation. It is triangular in shape, 2^ inches in length 
by 2 inches in breadth, and very thick. Tbe inner sur* 
faces are smooth and present numerons orifices of glands 
and depressions, bnt there are no traces of chorionic villi, 
nor any indication that there ever have been any. The 
outer surfaces are rough with papillary elevations, each 
papilla, being about the size of a grain of wheat, is attached 
by one extremity to the superficial part of the decidua, 
and projects obliquely from it. 

Under the microscope the decidua is seen to be com- 
posed of the characteristic nucleated epithelioid cells of 
various sizes, with numerous leucocyte- like cells inter- 
spersed. Blood-vessels are fairly numerous but are not 
very large. Each papilla examined contains a consider- 
•able cavity, which opens by a much smaller orifice on to 
•the surface. 

This structure resembles all the specimens of uterine 
decidua in cases of extra-uterine gestation which I have 
examined, and closely the decidua vera of intra-nterine 
pregnancy, though in the latter I have only met with 
these papillary projections in much smaller numbers. 

I had the advantage of Mr. Bruce Clarke's assistance 
when the examination under the anaesthetic was made, 
but we were unable to arrive at a positive diagnosis ; we 
had very strong evidence of pregnancy in the amenorrhoea 
of three months' duration, the presence of morning 
sickness, and the enlargement of the breasts ; we had the 
strongest possible evidence that the pregnancy was not 

ers of the cast ; but, on the 
le to find any evidence ot* an 
therefore decided to place the 
ho was an intelligent woman, 
le question of an exploratory 
ut that the risk of such an 



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EYIDENCB OF EXTRA-UTEBINE GESTATION. 337 

operation was in our opinion not greater than she 
might fairly meet to have so important a matter decided, 
and she agreed to it without hesitation. 

On AngQSt 1 st this was done by Mr. Brace Clarke. 
We made a careful examination of the pelvis and tubes, 
and found no evidence whatever of extra-uterine gestation. 

There is nothing to record in the after history of the 
case; her recovery was slightly interrupted by suppu- 
ration in the lowest part of the deep wound in the thick 
layer of fat. 

The importance of this case is very great, for it appears 
to prove the unreliability of one of the most character- 
istic phenomena of extra-uterine pregnancy for the 
purposes of diagnosis. Some of us at least have looked 
upou the extrusion of such a decidua as absolutely 
indicative of extra-uterine gestation, and I know of no 
previous evidence contrary to this. This question, then, 
needs consideration : What are these decidual casts, and 
under what conditions are they formed ? 

It is not a little remarkable that in spite of the great 
attention which has been given of recent years to the 
whole subject of extra-uterine gestation, so little has been 
devoted to this point ; while some authors, Charpentier 
and Winckel, for instance, refer to it in some detail 
(Winckel regarding the decidua as diagnostic); others 
merely mention it as an occasional symptom, and some do 
not even refer to it. 

Decidual casts from the uterus are known to occur 
under three distinct conditions : (1) as menstrual exfoli- 
ations in the condition known as dysmenorrhoea mem- 
brauacea ; (2) in extra-uterine gestation ; and (3) from 
the non-gravid horn of a double uterus. I have 
examined several specimens from the first and second 
of these in cases the diagnosis of which was placed 
beyond doubt. 

The characters of the different casts are quite distinct 
both to the unaided eye and histologically. 

The menstrual decidua is rarely shed entire ; mos^ 



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838 IMFOBTANCE OF A DECIDUAL CAST AS 

frequently that from the anterior and posterior walls are 
torn apart^ owing probably to their extreme thinness. 
It is often shed in several small fragments. 

When placed together^ the fragments form a triangular^ 
very thin and translucent sac^ measuring from an inch to an 
inch and a quarter in length and width. Microscopical 
sections exhibit the structure presented by the normal 
menstruating mucous membrane of the uterus in the 
early stage^ namely^ the uterine glands embedded in the 
loose connective tissue^ the surface covered by a single 
layer of columnar epithelium. In places the epithelium 
and subepithelial connective tissue have been lacerated by 
the bursting of the superficial blood-vessels, and in the 
deeper parts extravasations of blood are seen due to the 
same cause. There is no development at any part of 
the large epithelioid cells so characteristic of pregnancy 
decidua. 

This is not the place to discuss the aetiology of this 
deviation from the changes which occur in normal men- 
struation, but it appears to me that the cause of the great 
differences of opinion that have been expressed as to the 
minute structure of dysmeuorrhoeal membranes by dif- 
ferent observers depends on the fact that insufficient 
care has been taken in selecting the membranes for exa- 
mination ; one takes a piece of blood-clot and naturally 
finds it to be composed of fibrin, another obtains his 
specimen from a woman who has lately been confined or 
has aborted, and finds the characteristic decidual cells, 
while a third examines a specimen from a case compli- 
cated by endometritis. I have had opportunities for exa- 
mining all these, but my own opinion is based on the 
examination of specimens passed by women, married and 
single, who had never been pregnant, and whose only 
pelvic trouble was their dysmenorrhcea, and in the case 
of the married women of sterility. Such uncomplicated 
cases should alone be taken in the first place for study, 
and the others added as variations, not as characteristic 
types. 



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EVIDENCE OF BXTRA-UTEBINE GESTATION. 389 

In Bnch cases I have never seen any more evidence of 
inflammation than is seen in perfectly normal menstru- 
ation^ — that is to say^ none at all. The specimens shown 
are from such cases uncomplicated by treatment. 

The decidua from the uterus in cases of extra-uterine 
pregnancy is easily distinguishable from menstrual de- 
cidua^ owing to its large size and great thickness. 
Microscopic sections show that the uterine mucous mem- 
brane with its glauds and surface epithelium is entirely 
replaced by the characteristic decidua of pregnancy which 
has not come into relation with the foetal chorion. 

The decidua from one horn of a double uterus^ the other 
horn being pregnant^ is again easily distinguishable from 
the others by its shape, which of course corresponds with 
the shape of the cavity of the cornu. The cornu in such 
cases is nearly cylindrical^ the fundus being no wider 
than the cervical end, and the oviduct springs from the 
centre of the fundal extremity instead of from the side, 
as in a normal uterus. The decidual cast, therefore, is 
nearly cylindrical — pencil-shaped instead of triangular. 

Much more closely resembling the decidua of extra- 
uterine gestation is the decidua vera of a normal preg- 
nancy, but this is not likely to be shed by itself except 
in cases of imperfect abortion, the ovum and the other 
membranes having been extruded previously ; but, of 
course, evidence of this may not easily be obtained. 

This case appears to be capable of explanation in 
one of two ways : either the uterus can develop the 
decidua which we have believed to be the result only 
of fertilisation of an ovum, without this stimulus; or, 
as appears to me to be less improbable, a fertilised ovum 
may have provided the necessary stimulus, either inside 
or outside the uterine cavity, and if within the uterus it 
has failed to attach itself to it, or even to initiate 
differentiation of the decidua which should immedi 
follow the entrance of the ovum ; if external to 
uterine cavity the ovum has so completely disappc 
as to leave no trace of its situation behind it. 



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840 IMFOBTANC£ OF A DECIDUAL CAST. 

It does not appear necessary^ until farther evidence is 
obtained^ that we should alter our opinion as to the value 
of this phenomenon in cases of suspected extra-uterine 
gestation^ further than to regard it as evidence of the 
highest value instead of as conclusive. 

Dr. Eemvbt inquired if the size of the uterus had been 
ascertained by passing a sound immediately after the expulsion 
of the decidua, as the evidence thus afforded would have an 
important bearing on the diagnosis of the case. 

Dr. LsiTH Napieb expresi^ the hope that the microscopical 
specimens shown might be figured in colours in the ' Transac- 
tions.' They aided greatly in supporting the author^s observa- 
tions, and being arranged in due sequence were most instructive. 



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DECEMBER 5th, 1894. 

G. Ebnest Herman, M.B., President, in the Chair, 

Present — 64 Fellows and 10 visitors. 

Books were presented by the Edinburgh Obstetrical 
Society, the Clinical Society of London, the Johns Hopkins 
Hospital, St. Thomas's Hospital, and the Medical Society 
of London. 

Herbert James Hott, M.D.Aber. ; William A. Stott, 
M.R.C.S. ; T. Vere Nicoll, L.R.C.P.Lond. ; and C. R. M. 
Green, L.R.C.P.Lond., were admitted Fellows. 

The following gentlemen were elected Fellows of the 
Society :— H. Bellamy Gardner, M.R.C.S. ; R. W, John- 
stone, M.D., B.Ch. ; Robert Thomas Alexander O'Calla- 
ghan, F.R.C.S.I. ; Herbert Edward Rayner, F.R.C.S. 

The following gentlemen were proposed for election : — 
Samuel Ruddell Collier, M.D. ; John Curtis Webb, 
B.A.Cantab. 



CURIOUS CONGENITAL DEFORMITY. 
By C. H. Roberts, M.D. 

Db. Roberts showed a case of curious c( 
deformity in a female child of three months old, 
ing the so-called intra-uteriue amputation of limbi 

VOL. XXXVI. 2< 



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842 CURIOUS CONGENITAL DEFOBMITT. 

The child^ which seemed perfectly well otherwise, was 
the fifth child of a German woman ; she had no other 
children deformed. Her confinement was easy, no instru- 
ments were used. No history of deficiency of the liquor 
amnii could be obtained. The cord was not round the 
limbs. The mother was " frightened *' by a burglar 
when two months pregnant. The child exhibited most 
marked deformities of the limbs, particularly on the left 
side, especially the left lower extremity. There was no 
deformity of lips, palate, neck, arms, back, or genitals. 
No coDgenital heart disease nor any transposition of viscera. 

The left forearm near the wrist exhibited a curious 
constriction. The three middle fingers of the left hand 
were stunted and webbed into one thick triangular finger. 

The left lower extremity was natural to the knee, 
below which was a curious shapeless mass of flesh three 
inches long, with three definite constrictions, containing 
only bone at its upper part. Lowest of all on this fleshy 
mass were five tiny outgrowths like toes. The child 
could move this, and the knee-joint was natural. 

The. right lower extremity was natural to the knee ; 
the leg just above the ankle was markedly constricted, as 
if a cord had been tied tightly round it. The foot was 
natural, but two toes were curiously webbed. 

Dr. Roberts thought it might interest some of the 
members of the Society as regards pathology and the 
question of congenital deformity caused by intra-uterine 
amniotic bands, or whether this was not a case simply of 
faulty development. He also wished for advice as to later 
treatment. 



The President (Dr. Herman) thought the case one of intra- 
uterine amputation by amniotic bands, and asked Dr. Roberts 
as to the amount of ^liquor amnii. 

Dr. SoBEBTS said that he rather leaned to the theory of 
faulty development. He was unable to inform Dr. Herman as 
to the question of deficient liquor amnii in this case. 

The Pbesident thought that constriction by amniotic bands, 
from deficiency of amniotic fluid was the most reasonable ezpla- 



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FIBBOHA OF OYABT. 843 

nation of deformities such as those present in the infant exhi- 
bited by Dr. Roberts. 

Dr. Qbiffith said that Dr. Lancereaux in a clinical lecture 
C Medical Weekly,' October 6th, 1894, p. 481) had put forward 
an explanation of these cases which appeared to be much more 
probable than any former theory, namely, that the disease, 
which he described as "autocopictropho -neurosis," was a disease 
of nerve-trunks. 



RUPTURED TUBAL PREGNANCY. 
By W. Atkinson Stott, M.R.C.S. 

The specimen is one of tubal pregnancy which ruptured 
during the thirteenth week. 

It consists of Fallopian tube with ovary and part of 
the broad ligament. The tube is distended in the middle 
portion the size of a hen's egg^ and the upper surface shows 
a T-shaped rent^ and its cavity the contained gestation 
sac. A separate nipple-shaped portion of the latter 
occurred free. Both the abdominal and uterine extremi- 
ties of the tube are patent. 

It was removed a fortnight ago^ twenty-seven hours 
after sudden onset of peritoneal haemorrhage from the 
patient^ who was almost moribund. 

The peritoneum contained almost three pints of blood* 
The patient is now rapidly recoyering. 



FIBROMA OF OVARY. 
By MoNTAOUB Hakdtibld Jonis, M.D. 



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844 



HYDATIDS IN THE BONY PELVIS. 

(With Plates.) 

By J. H. Taeoitt, P.R.C.S. 

{Abstract.) 

Mb. Tabobtt gave a demonstration on hydatid disease of 
the pelvis, illustrating his remarks by a large number of lantern 
slides. The consideration was limited to examples of the 
disease as it affects the bones of the pelvis, and all cases of 
hydatids in the soft tissues of the pelvic cavity were excluded. 
After classifying the specimens as those of primary disease in 
the OS innominatum or sacrum, ajid as those due to extension 
from the spinal column or femur, it was pointed out that the 
lesion was characterised by a wide-spread destruction of the 
interior of the os innominatum, and separation of its compact 
lamellsB. As the ilium was usually first affected, these morbid 
changes resulted in the formation of a lai^e cavity with thin bony 
walls, in which were many perforations. The contents of the 
cavity comprised pus, hydatid cysts, and spongy sequestra 
derived from the necrosed cancellous tissue. By the apertures 
in the walls much of the contents of the cavity escaped beneath 
and among the muscles attached to the pelvis, thus forming 
large swellings in the groin, buttock, thigh, or iliac fossa. Such 
tumours had the clinical features of large chronic abscesses ; 
they were generally painless, perhaps inconvenient on account 
of their size, and some had been found to be partially reducible. 
In the later stages of the disease the destruction involved all 
parts of the bone, and in a large proportion of the cases the 
acetabulum was laid open, and the upper end of the femur 
attacked. 

Photographs were shown representing one half of the pelvis 
80 completely destroyed that only irregular fragments of the os 



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DESCRIPTION OP PLATES VI and VII, 

niustrating Mr. Targett^s paper on Hydatids in the Bony 

Pelvis. 

Fig. 1 (Stanley). External aspect of right half of pelvis, showing 
excavation of the ilium, and a large aperture in the acetabulum. 

a. Head of femur. 

b. Posterior spine of iliac crest, 
c Side view of sacrum. 

Fig. 2. Internal aspect of same preparation. There is a wide 
cavity in the front of sacrum. 

Fig. 3 (R^czey). Pelvis after maceration. Bight side destroyed 

a. The porous head of the femur. 

b. Wire on which the fragments are strung. 

c. Soft parts which still hold the head of the femur in place. 
Fig. 4. The upper end of the right femur showing the fractured 

surface. The cancellous tissue of the shaft is much excavated. 

Fig. 5 (Yiertel). Pelvis with last three lumbar vertebrsB and upper 
ends of femora after maceration. 

A. Posterior end of iliac crest. 

B. Remains of floor of acetabulum. 
0. Bight ischiatic spine. 

S. Symphysis pubis. 

a, b. Articular surfaces on ilium for femur. 

a, b. Articular surfaces on femur. 

Tm. Trochanter major. 

Tmin, Trochanter minor. 

K, Upper end of cervix femoris. 



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Plate VI 



z?.... 



F19.]. 



We8t,TiewTna.Ti lit'h. 



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Plate Vfl 



pig.'t'. 



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HYDATIDS IN THE BOKY PSLYIS. 845 

innominatum persisted, and in consequence the extremity of the 
femur had passed inwards as far as the front of the sacrum, 
thus causing yery marked shortening of the thigh. There was 
little or no evidence of compression of the pelyic yiscera by the 
hydatid swellings, and no case of dystocia from this cause had 
been recorded. In this respect hydatids of the pelvic bones 
differed most markedly from those developed in the soft tissues 
of the pelvis. The very high rate of mortality which had 
attended the operative treatment of these swellings was men- 
tioned. Out of fifteen cases twelve died, and the cause of death 
in almost every instance was septic absorption. In conclusion, 
the mode in which disease extended from the spinal column on 
the one hand, or from the femur on the other, was fully 
described and illustrated. 

The development of hydatids in the human skeleton is 
a very rare occurrence. Some seventy-six cases only 
have been placed on record^ and these include examples 
from almost every part of the skeleton. Out of this 
small number of cases, however, the bony pelvis absorbs 
a comparatively large share, for there are twelve instances 
in which the os innominatum was the primary seat of the 
disease, and three which may be referred to the sacrum. 
Putting these together it follows that in one fifth of the 
total number of cases of hydatids in the osseous system 
the bones forming the pelvis were the parts first affected. 
It must be clearly understood that hydatid cysts origi- 
nating in the soft tissues of the pelvis are entirely 
excluded from the subject now under consideration, as 
they have a different life-history and present totally 
different clinical symptoms. Beside the formation of 
hydatids in the os innominatum or sacrum, as the case 
may be, there are two other modes in which the bony 
pelvis may become affected, viz. by extension of the 
disease from the spinal column, or from the femur. The 
cases here recorded are, therefore, classified as (a) Primary 
Hydatid Disease of Os Innominatum; (6) Primary Hydatid 
Disease of Sacrum; (c) Hydatids of Spine invading Pelvis: 



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846 HYDATIDS IN THE BONY PELVIS. 

(d) Hydatids of Femur invading Pelvis. The phrase 
" hydatid disease/' as here employed^ denotes the changes 
wrought in the substance of the affected bone by the 
growth and reproduction of the hydatid cyst derived from 
the embryo of the taenia echinococcos. A full account of 
those changes as met with in the long bones of the extremi- 
ties will be found elsewhere^* and need not be repeated. 
Suffice it that three stages of this disease are described 
—firstly, infiltration of the cancellous tissue with minute 
hydatids, which multiply by budding from the exterior 
of the cysts; secondly, excavation by gradual absorption 
of the osseous septa and consequent enlargement of the can- 
cellous spaces ; and thirdly, suppuration, which results in 
a more rapid destruction of the cancellous tissue, and in 
the formation of spongy sequestra and external swellings. 
When suppuration has supervened its effects overshadow 
those due to the growth of the hydatids, and to a large 
extent change the nature of the lesion ; so that while the 
initial stages of the disease are insidious and of long 
duration, the formation of pus in the affected bone with 
its well-known burrowing tendencies is not slow to declare 
itself. As a matter of fact the disease has usually come 
under observation in this suppurative stage, and in the 
following cases it will be noted that all those primary in 
the pelvic bones presented without exception some swelling 
external to the affected bone which was recognisable 
clinically. In short the consideration of these clinical 
histories may be said to resolve itself into an account of the 
characters of certain chronic purulent swellings attached 
to the bones of the pelvis. 

Before dealing with the morbid anatomy and symptoms 
of this disease, a few remarks on its etiology will not be 
out of place. Neither sex nor age would seem to have 
any influence upon it. The youngest patient among the 
primary series was twenty- three, and the oldest sixty-three. 
But hydatids in other parts of the skeleton have been met 
with in childhood, land in Case 19 the disease existed 
• ' Guy's Ho»p. Rep./ vol. 1, p. 309. 



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HYDATIDS IN THE BONY PELVIS. 847 

at the age of ten. How the echinococcns embryo is 
introduced into the body^ whether by certain articles of 
diet^ freqaent contact with dogs^ or uncleanly habits^ is 
not definitely known. When once it has reached tbe 
circulation it is of interest to inquire what determines its 
deposition in the osseous system. Has injury anything 
to do with it f Of the fifteen cases in only three was the 
disease attributed to a local injury^ such as a bruise from 
a fall. In Case 9 the patient fell from his horse and 
received a severe contusion on the hip^ from which he 
never completely recovered; and when seen two and a 
half years afterwards he presented the symptoms of 
advanced hip disease on the injured side. In Case 5 
the injury was received nineteen years before the patient 
came under observation ; yet throughout that long period 
of time there had been pain and some swelling. It is 
stated that the prominent hip-bones of the ox^ exposed 
to blows and injuries of various kinds^ are not uncom- 
monly affected. A good example of the kind is preserved 
in the College of Surgeons Museum (No. 1698).* Evidence 
of injury derived from the histories of cases in which the 
long bones were affected is equally inconclusive^ though 
it may be truly said that those bones which are most 
exposed to traumatism have been most often affected. 
Hence it is probable that injury has some influence in 
determining the site at which the hydatid becomes 
deposited in the osseous system. 

Morbid Anatomy. 

1. The changes in the bones. — Among the twelve cases 
of primary disease in the os innomiuatum^ the iliac por- 
.tion of the bone was invaded in all but one^ and in ten 
instances it was the chief seat of the affection. The large 
proportion of cancellous tissue here accounts for this fre- 
quency^ and the same explanation would apply to the 
upper end of the tibia^ the humerus^ and the femur^ 
• See ' Qay'f Hocp. Rep./ vol. 1, p. 886. 



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848 HYDATIDS IN THE BONY PELVIS. 

which are the parts commonly selected from the bones 
of the extremities. By the destruction of its interior and 
the separation of the two lamellae of compact tissue the 
ilium is converted into a thin-walled sac which bulges on 
both external and internal surfaces of the bone. The 
wall of this sac is composed of a thin layer of bone crepi- 
tating on pressure, or merely an imperfect capsule of 
bone having large irregular perforations in it ; sometimes 
the osseous tissue entirely disappears, and the adjacent 
soft parts are thickened and form a limiting membrane. 
The contents of the hydatid cavity in the bone comprise 
a variable quantity of serous or purulent fluid, numerous 
hydatid cysts, and spongy sequestra the interstices of 
which are filled with budding cysts. From the ilium 
the process of excavation advances into the body of the 
ischium, lays open the acetabulum, and may eventually 
reach the horizontal ramus and body of the pubes. In 
Case 7 the os pubis was the original seat of the disease, 
and the ilium was not affected. In the pubes as well as 
in the ischium the growth of the hydatids produces irre- 
gular excavations with wide mouths facing towards the 
pelvic cavity. Owing to the structure of the bones they 
are not expanded into osseous sacs like the ilium. In 
-no instance has the hydatid cavity been lined with a 
mother cyst-wall ; when a lining membrane has been 
observed there was good evidence to show that it was of 
a pyogenic nature and that the contents of the cavity were 
purulent. 

2. The perforation of the acetabulum. — One of the most 
striking anatomical facts connected with the occurrence 
of hydatids in the bony pelvis is the frequency with which 
the acetabulum is penetrated. It was met with in nine out 
of the twelve instances of primary disease of the hip-bone. 
The degree of perforation varied from a small aperture 
in the iliac or pubic segment to a destruction so complete 
that the acetabulum formed part of a large sac replacing 
much of the hip-bone, or was entirely unrecognisable. 
To this invasion of the acetabulum several of the im« 



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HYDATIDS IN THE BOKY FELYIS. 849 

portant clinical symptoms may be referred. But though 
the acetabulum was severely affected^ the changes in the 
head of the femur were much less marked. In Case 4 
it was practically normal ; in three other instances it was 
described as carious^ while in Cases 10 aud 11^ where the 
destruction of the pelvis had reached its greatest limits 
the head of the femur had disappeared and the cervix 
femoris was infiltrated with hydatids. Where a wide 
perforation in the acetabulum existed^ the upper end of 
the femur was subjected to a remarkable displacement. 
When the aperture occupied the floor of the acetabulum^ 
the femur was thrust into the pelvic cavity as far as the 
small trochanter ; and when it communicated with a large 
sac in the ilium, the extremity of the femur was inserted 
between the osseous lamellae^ and even reached the level 
of the first two anterior sacral foramina on that side. In 
consequence of this dislocation considerable shortening of 
the affected limb resulted. 

3. Extension to the sacrum. — In four preparations 
disease was found in the sacrum as well as in the os in- 
nominatum^ but in all of these the primary seat was 
undoubtedly in the latter. Two large excavations were 
found in the anterior surface of the sacrum in Case 4^ 
and careful dissection showed the probable tracks by 
which disease had extended from the ilium to the sacrum. 
In doing so it appeared to have avoided the sacro-iliac 
synchondrosis after the manner in which cartilage is 
known to resist the invasion of new growths. Similarly 
in Case 1 the synchondrosis was exposed but not attacked. 
However^ from the description of the preparation in Case 
9, it would seem that this joint eventually succumbs^ and 
the destruction of the sacrum with perhaps the adjacent 
lumbar vertebraB is then extensive. The possibility of a 
focus of disease in the sacrum which is entirely separate 
from that in the os innominatum must be borne in mind. 
Such a condition has been described in certain of the long 
bones^ but the evidence in favour of this occurrence is 
not very satisfactory. 



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350 HYDATIDS IN THE BONY PBLVI8. 

The pecaliarities in the effects of hydatids upon the 
sacrnin depend for their importance on the relations of 
the bone. Being largely composed of cancellous tissue, 
the sacrum is readily excavated, and by means of its 
numerous foramina, disease extends without difficulty to 
the spinal canal, to the vertebral groove posteriorly, and 
towards the pelvic cavity in front. Through the poste- 
rior sacral foramina hydatids find their way into the 
erector spinas muscles, or form a swelling on the back of 
the sacrum (Cases 4, 9, 13, 14, and 15). The effect of 
hydatids extending into the spinal canal and coming into 
relation with the cauda equina is less marked than might 
be expected, for in only one of the five cases just quoted 
was there evidence of compression of the nerves, viz. severe 
sciatica ending in paraplegia (Case 14). If the sacral 
swelling protrudes forwards towards the pelvic cavity, its 
presence may be detected through the rectum or vagina, 
as in Cases 14 and 15. Under such circumstances the 
possibility of pressure being exerted upon the rectum or 
other of the pelvic viscera must not be overlooked. 

4. Formation of swellings on the 6on6«.— As already 
pointed out, this is a very characteristic feature of the 
disease, for it was present in each of the fifteen cases now 
underconsideration. Two points demand attention : firstly, 
the seat of the swelling, and secondly, its physical signs. 
It must be understood that this swelling, which is recog- 
nisable clinically, is the result of perforation of the wall 
of the hydatid cavity in the bone and extravasation of 
. its contents ; moreover, it is chiefly due to the occurrence 
of suppuration in the cavity. That some swelling of the 
ilium may be produced by the bulging outwards of its 
compact lamellae, either towards the buttock or the iliac 
fossa, is certainly true, and is described in some of the fol- 
lowing capes. But this can hardly occur in other parts of 
the bony pelvis, and is not likely to be very conspicuous in 
any region. Since the iliac portion of the os innominatum 
is most commonly affected, it is natural to suppose that 
the external swelling will usually be related to that bone. 



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HYDATIDS IN THE BONY PELVIS. 851 

In six instances it was found upon tlie buttock^ the fluid 
having burrowed outwards from the ilium beneath the 
gluteus maximus. Thence it extended over the back of 
the sacrum^ or was conducted by the gluteus to the outer 
surface of the thigh. When the hydatid cysts and pus 
become effused among the muscles of such parts as the 
buttock and inner side of thigh^ the soft tissues soon 
become riddled with abscesses (see Cases 5 and 19). If 
extension from the ilium takes place inwards^ the swelling 
is either limited to the iliac fossa^ or appears in the groin 
by following the course of the ilio-psoas muscle. The 
groin is therefore the next most frequent site of the 
swelling. In the cases (7 and 10) where the pubes was 
much destroyed^ the swelling occupied the inner end of 
the groin and the adjacent portion of the thigh ; or was 
situated in the abdominal wall^ having burrowed upwards 
between the muscles and the peritoneum halfway towards 
the umbilicus ; or again^ the abscess extended from 
behind the pubes through the obturator foramen to the 
npper third of the thigh. It will be observed that these 
modes of extension of the hydatid swelling are along 
lines which are familiar as the course taken by pus from 
hip disease and other suppurative infections of the pelvis. 
Protrusion of the swelling into the cavity of the true 
pelvis does not seem to be a frequent occurrence. In 
Case 8 a hard intra-pelvic swelling was detected per 
rectum upon the inner surface of the acetabulum ; and in 
Case 10^ where the hip-bone was extensively diseased^ the 
pelvic cavity had become contracted in certain diameters. 
Yet as a rule hydatids in the bony pelvis cause little or 
no encroachment upon its cavity^ hence they do not lead 
to visceral obstruction. ^Thus they may be sharply dis- 
tinguished from hydatid cysts originating in the soft 
tissues of the pelvis. 

The physical signs of the hydatid swelling most nearly 
resemble those of a cold abscess. They are usually 
painless^ without redness or heat^ distinctly fluctuating^ 
and exceedingly chronic. The outline of the swelling is 



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352 HYDATIDS IN THE BONY PELVIS. 

not very distinct from the abundance of flesh about the 
pelvis^ but in Case 4 the swelling is described as '^ globular 
and somewhat pendulous/* Where two or more swellings 
existed at the same time^ it was noted that an inter-com- 
munication was present^ for fluid could be forced from the 
one to the other. In like manner the swelling may be 
more or less reducible^ tbe fluid being driven back into 
the cavity within the bone. By this means the outline of 
the expanded bone may be felt^ and crepitus obtained by 
pressure on its thin osseous wall. A hydatid thrill has 
also been described. The fluid obtained by puncture of 
the swelling will vary in character according to the 
admixture with pus. If the latter is absent^ the material 
will resemble the typical hydatid fluid. In two respects^ 
however, it differs from that obtained from a visceral 
hydatid cyst, viz. in the absence of booklets, and in the 
presence of exogenously budding capsules. In Case 2 
booklets were found, and they have been described in a 
few specimens from other parts of the skeleton. But 
their occurrence must be regarded as exceptional. 

Symptoms and Treatment. 

In the earlier stages of the affection no definite 
symptoms are recognised. But where the osseous changes 
have been attributed to a preceding injury, the clinical 
history of the case describes a prolonged weakness and 
deep-seated pain in the injured part. In one instance 
the pain is mentioned as tearing and boring in character. 
With the onset of the hydatid swelling upon the bone, 
the existence of some disease is indicated, and it is in this 
stage that the case comes under observation. It is in- 
teresting to observe that out of the twelve cases of 
primary hydatid disease of the hip-bone, no less than six 
were diagnosed as chronic abscess probably due to disease 
of the hip-joint, and in some of these cases the patients 
presented the deformity and position of limb commonly 
seen in hip disease. But in spite of this strong general 



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HYDATIDS IN THE BONY PELVIS. 853 

resemblance^ there are certain features which are im- 
portant for differential diagnosis. Shortening of the limb 
when present is excessive^ because it is due to perforation 
of the acetabulum and protrusion of the femur into the 
pelvis. The painlessness in the later stages of the disease 
is noteworthy, and unlike coxitis ; in several instances the 
patients were able to get about with no more inconveni- 
ence than what was caused mechanically by the presence 
of large hydatid swellings about the pelvis. A character- 
istic symptom of hydatid disease in a long bone is the 
occurrence of a spontaneous fracture followed by a 
swelling at the seat of injury — the order of events being 
the reverse of that met with in malignant disease. 
Obviously such a symptom cannot apply to the pelvis^ 
though in Case 11a spontaneous fracture of the cervix 
femoris took place shortly before death. When a hard 
swelling is found upon the iliac fossa^ typical egg-shell 
crackling may be elicited^ and the sign indicates a thin 
bony wall to the swelling. Externally it is less likely to 
be recognised^ owing to the thick covering of soft tissues. 
It will be seen, then, that there are no very character- 
istic indications of the existence of hydatids in the bones 
of the pelvis, apart from the results of an exploratory 
operation. The rarity of the disease likewise makes a 
correct diagnosis improbable. The most important indica- 
tions may be thus summarised : 

a. The presence of swellings in the buttock, groin, or 
thigh having the characters above detailed. 

b. In the majority of the cases there is a general 
resemblance to disease of the hip-joint; less frequently 
sacro-iliac disease or chronic periosteal abscess of the 
ilium is simulated. 

c. No evidence of interference with the functions of 
the pelvic viscera ; in advanced cases, however, the pelvio 
cavity is likely to become distorted in consequence of the 
extensive destruction of bone. 

(2. The nature of the fluid obtained by puncture of the 
swellings, or spontaneous rupture ; especially as regards 



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854 HYDATIDS IN THE 60NT PELVIS. 

the presence of budding hydatids and seqaestra of can- 
cellous bone. 

As regards treatment it is very necessary to point out 
the high mortality of this disease. With the exception 
of Cases 5 and 6 all the fifteen cases of hydatids primarily 
in the os innominatum and sacrum were submitted to 
surgical treatment^ and twelve of the fifteen died^ while 
three recovered. Without attempting an exact analysis 
of the cause of death in each instance^ it may be said that 
the great majority died of pyaemia^ or more rapidly from 
septic absorption. The importance of strict antisepsis in 
dealing with large hydatid swellings^ such as we have de- 
scribed above, will be readily admitted. The line of 
treatment which led to a successful issue in Cases 2, 3, 
and 15 was free incision and thorough evacuation of the 
hydatid swellings ; and it is interesting to note that in 
Cases 2 and 3 operation was followed by definite symptoms 
of septic absorption, though recovery ensued. The diffi- 
culty which is experienced in the complete removal of the 
minute cysts from the cavities in the bones is shown by 
the necessity for a repetition of the operation in so many 
instances. When the cavity can be reached it should be 
thoroughly laid open, its interior well scraped, and ade- 
quate drainage provided. Large deeply-placed cavities 
or sacs attached to the inner surface of the hip-bone 
might be treated by Bond's method, which consists in 
careful removal of the contents of the sac and application 
of iodoform to the interior, the opening in the sac being 
left unclosed. Complete enucleation of the sac from the 
soft parts, where it can be effected, offers the best chance 
of a speedy cure. 



A. Pbtmabt Hydatid Disbasx or Os Innominatum. 

Case 1 (St. George's Hosp. Museum, No. 14 B). — ^A 
butcher, aged 59, was admitted to the hospital for a dis- 
charging sinus in the right thigh. Sixteen months pre- 



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HYDATIDS IN THS BONY PELVIS. 35& 

viouslj a swelling appeared on the back of the thigh^ 
which gradually increased, and ultimately burst about 
three mouths before admission. The sinus was situated 
4 inches below the great trochanter, and discharged an 
abundance of pus. When freely laid open several pieces, 
of necrosed bone were removed. The skin over the 
sacrum and the back of the ilium was found to be much 
undermined. Death occurred from pneumonia nearly four 
weeks after admission. 

Autopsy. — There was a cavity in the ilium which con- 
tained a little thin pus, many hydatid cysts and small 
sequestra. Through a perforation in the posterior wall 
of the cavity numerous hydatids had passed into the 
vertebral groove and were lying among the deep muscles 
of the back. 

Description of the specimen (' Guy's Hospital Rep./ 
vol. 1, p. 337). — Within the ilium there is a disc-shaped 
cavity measuring 3 inches in diameter, formed by separa- 
tion of the two tables of the ilium and excavation of the 
intervening cancellous tissue. This space reaches up* 
wards to the crest and backwards to the posterior spines 
of the ilium, while anteriorly it is bounded by a vertical 
line through the apex of the great sacro-sciatic notch. 
Its superficial wall is formed of a thin fenestrated shell 
of compact tissue, while on its deep surface the cartilaore 
of the sacro-iliac joint is exposed. One half of the 
cavity has been emptied of its contents, and here a thin 
lining of pyogenic membrane is visible. The remainder 
of the space is packed with necrosed and partially detached 
spongy bone, saturated, so to speak, with minute hydatid 
cysts and pus. There are three large and several small 
fenestrae in the external wall of the space, and pus was 
probably discharged through them into the tissues beneath 
the glutei muscles. Another perforation at the posterior 
superior iliac spine opens into the vertebral groove beneath 
the erector spinsB muscles^ and near by^ lying upon the 
arches of the last two lumbar vertebrae^ is a smooth-walled 
multilocular cavity containing a few shrivelled hydatid 



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856 HYDATIDS IN THX BONY PXLYIS. 

cysts. From this spot other cysts can be traced through 
the deep muscles between the lumbar spine and sacrum to 
the front of the preparation, where many are embedded 
in the substance of the psoas muscle aboYe the dacro-iliac 
joint. The surrounding soft parts are here matted by 
dense inflammatory tissue. 

Case 2 (Bardleben, 'Berlin, klin. Wochen./ 1888, 
p. 825). — A washerwoman, aged 28, was deliYored in 
JS'oYember, 1882, and in the following January (1888) a 
tumour formed in the left inguinal region. This was ex- 
plored, and was considered to be due to disease of the ilium. 
On April 17th, as the tumour had increased much in size, 
A long incision was made reaching to Ponpart's ligament, 
and a suppurating track was discoYered, along which the 
finger was passed to the brim of the pelYis. Some thick 
pus escaped, and the wound was irrigated. During the 
next few days the patient had rigors, and her general 
45ondition was bad. 

May 8rd. — While changing the dressings a small 
hydatid cyst was discoYered ; characteristic booklets and 
the laminated cyst-wall were recognised by the micro- 
scope. Patient complained of sharp pains in the hepatic 
region ; she was jaundiced, and the urine was deeply 
tinged with bile. 

7th. — The sinus was enlarged and explored with the 
finger. By this means a swelling of the ilium was 
detected, the thickness of which was determined bimanu- 
ally, the opposite hand being placed on the exterior of 
the hip-bone. Another incision was made at the poste- 
rior part of the iliac crest, the muscles were diYided, and 
both surfaces of the ilium were laid bare. This pro- 
cedure exposed a caYity in the ilium containing hydatids. 
The osseous cavity was laid open freely, and the interior 
thoroughly scraped. A large number of hydatids were 
xemoYed, varying in size from a pea to a pigeon's egg. 
The wound was drained and kept aseptic ; the jaundice 
disappeared in a few days, and the patient was discharged 



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HYDATIDS IN THE BONY PELVIS. 857 

on August Ist in good health with the wound quite 
healed. 

Owing to the extent of the disease in the ilium it was 
thought possible that the hip-joint might have been 
involved, but there were no symptoms of it. 

Case 8 (Thomas, ' Hydatid Disease/ vol. ii, p. 127). — 
A woman aged 28 came under observation for pain in the 
region of the right sacro-iliac articulation and a deep- 
seated elastic swelling beneath the gluteus maximus. 
Her illness began three years previously. The swelling 
was incised and clear hydatid fluid evacuated, but septi- 
C89mic symptoms soon followed, necessitating free inci- 
sions. Great improvement ensued ; still a third operation 
was required, and it was then found that a hydatid 
cavity occupied the substance of the right iliac bone, and 
had caused considerable destruction of the osseous tissue. 
Numerous small hydatids filled the cavity, and had to be 
cleared out with a gouge and osteotrite. The patient 
made a satisfactory recovery, and was known to be living 
six years after the operation. 

Cask 4 (Stanley, ' Diseases of the Bones,' 1849, p. 190). 
— A woman aged 54 was admitted into St. Bartholomew's 
Hospital with a globular and somewhat pendulous tumour, 
about the size of the closed hand, situated upon the 
buttock directly over the right sacro-iliac articulation. 
She stated that it had been five years in progress. A 
few weeks before her admission it had been punctured, 
and purulent fluid mixed with hydatids was discharged. 
The tumour again enlarged to its original size, and when 
punctured a second time only purulent fluid escaped. A 
free incision was now made into the tumour with the 
effect of liberating a large quantity of hydatids together 
with fragments of bone and purulent fluid. Severe con- 
stitutional derangement ensued, which in a few weeks 
proved fatal. 

Autopsy. — On examination numerous globular hydatids 
VOL. xzxvi. 25 



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858 HYDATIDS IN THE BONY PELVIS. 

were found in tlie interior of the right os innominatum^ 
and also within the sacrnm. In both these bones the 
cancellous structure had disappeared^ and the surround- 
ing walls were much thinned and widely separated from 
each other^ a large cavity being thus formed in the bone 
in which the hydatids were lodged. There were also 
apertures in the walls of each bone through which some 
of the hydatids had escaped into the surrounding soft 
parts. The cavity in the sacrum communicated with the 
spinal canal^ and the latter contained numerous hydatids. 
Each osseous cavity was lined with a smooth white mem- 
brane. A mass of hydatids, apparently unconnected 
with the affected bones^ was found among the erector 
spinaB muscles^ and another collection of vesicles occupied 
a cyst attached to the ovary. 

Description of the specimen (' Guy's Hospital Reports/ 
vol. 1, p. 886). — ^The specimen^ as preserved in St. Bar- 
tholomew's Hospital Museum, No. 541, consists of the 
right half of the pelvis with the head of the correspond- 
ing femur. Almost the whole of the cancellous tissue of 
the ilium has disappeared, and the bone is converted into 
a thin shell, the walls of which are formed by its external 
and internal tables of compact tissue. These tables are 
much perforated, particularly on the exterior of the bone, 
where it has a basket- like appearance; and in places 
they are widely separated from each other, though for 
the most part the normal shape of the bone is maintained. 
Superiorly this excavation in the ilium is limited by the 
crest, and inferiorly it communicates with the hip-joint 
by a wide aperture. Within the acetabulum the liga- 
mentum teres, cotyloid ligament, and much of the 
articular cartilage remain, while the head of the femur 
shows no evidence of erosion. Posteriorly, where the 
gluteus maximus arises the ilium is much expanded, and 
the cavity within the bone communicates by two or three 
small openings with a large space in the right ala of the 
sacrum. The sacro-iliac synchondrosis is not perforated, 
but the passages of communication run above, behind. 



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HTDAT1D8 IN THE BONY PELVIS. 859 

and below the joint. The excavation in the sacram is 
aboat the size of a hen's egg ; it has a large opening into 
the pelvis in front, in the site of the anterior sacral fora- 
mina, and becomes continaoas with the spinal canal just 
below the last lambar vertebra. A second mach smaller 
cavity exists towards the apex of the sacram, which 
commanicates near the posterior inferior iliac spinous 
process with the cavity in the iliam. The apper poste- 
rior sacral foramina are considerably enlarged, whereby 
the cavity in the sacram opens into the vertebral groove. 

Case 5 (Fricke, 'Hambarg Zeitsch. f. d. ges. med.,' 
1838, Bd. vii, p. 383). — A man aged 60 was admitted 
under the care of Professor Fricke. Nineteen years pre- 
viously he had had a fall upon the ice, and since that tiuie 
had experienced pain in the hip and ischial tuberosity. 
A tumour appeared on the buttock and gradually enlarged. 
It was fluctuating, but not painful, though deep-seated 
pains were often felt in the pelvis. The tumour interfered 
with walking, but did not absolutely prevent it. Death 
resulted from hectic fever. The diagnosis was chronic 



Autopsy, — ^There was a large tumour of the right thigh 
extending from the anterior superior iliac spine down- 
wards to the junction of the upper and middle thirds of 
the thigh, and backwards into the buttock. By punc 
a large quantity of fluid like pea-soup was drawn 
containing numerous hydatid cysts. An incision neai 
great trochanter showed that the gluteal muscles i 
riddled with large cavities filled with hydatids, 
capsule of the hip-joint was disorganised, and the ac 
bulum contained yellow fluid and small cysts. A 1 
below the anterior superior iliac spine there was a tr 
parent sac extending into the pelvic cavity. This 
tained an enormous number of hydatids, and communic 
with the acetabulum by two small openings. Pressur 
the pelvis caused many cysts to escape from this 
Another cavity occupied by hydatids upon the ilio-p 



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860 HYDATIDS IN THB BONY FSLYI8. 

commnnicated indirectly with the hip-joint through the 
ilio-psoas bursa. In the cancellous tissue of the right ilium 
a space the size of a fist had formed ; it involved abo 
much of the ischium and the horizontal ramus of the 
pnbes, and opened into the acetabulum through a large 
aperture in the vault. The head of the femur was rough 
and carious. The hydatids varied in size from a pigeon's 
egg to small pearls. In some places several cysts were 
found enclosed in one large sac, in others they were free. 
The primary focus appears to have been in the ilium and 
ischium^ where the destruction of bone was the most ex- 
tensive. 

Case 6 (Rokitansky, 'Path. Anatomy/ vol. iii,p. 134). 
— A labourer aged 42 had suffered from swellings of the 
cervical and axillary glands; and five years before his 
death, from gonorrhoea, chancre, and consequent bubo. 
Still later his penis had been amputated on account of 
malignant ulceration. The disease which was afterwards 
found in his bones began one year before his death with 
pains of a tearing and boring character. 

Autopsy. — The left ilium was found to be converted into 
a fibrous sac as large as a man's fist. This contained 
numerous small and large splinters of bone adherent to 
the inner surface of the sac, as well as hydatid cysts 
varying from the size of a millet-seed to that of a nut. 
Similar sacs of less dimensions were found in the pubes, 
ischium, and sacrum, and projecting from these bones into 
the pelvic cavity. Some of the hydatids were free, but 
others, especially the smaller ones, were situated in the 
dilated cancellous spaces of the eroded fragments of bone. 
In this situation they were arranged either singly or in 
clusters. The floor of the acetabulum was completely 
destroyed, and the head of the femur projected into the 
large sac which occupied its place. 

Case 7 (Denonvilliers, ' Bull. Soc. Anat.,' 1856, p. 119). 
— ^A woman aged 47 was admitted under the care of 



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HYDATIDS IN THE BONY PELVIS. 861 

M. Denonvilliers for a tumour upon the upper and inner 
part of the thigh. It was soft, painless, and about the 
size of the fist. The diagnosis was lipoma or chronic 
abscess. The swelling was incised and pus liberated, but 
the cause of the abscess was not discovered, though the 
wound was carefully probed. The patient died three 
days after the operation. 

Autopsy. — There wasan abscess behind the pubes and the 
left thyroid foramen. The horizontal ramus of the pubes 
was bare, and infiltrated with hydatid cysts. From this site 
the hydatids extended inwards into the vertical ramus of 
the pubes and outwards to the acetabulum, which was 
perforated in two places. The hydatids were not enclosed 
by a parent cyst, but infiltrated the cancellous tissue of 
the affected bones. The abscess behind the pubes had 
burrowed through the thyroid foramen, and presented as 
a swelling at the top of the thigh. As the pubes was 
bare only on its posterior surface, nothing was detected 
by the probe at the time of the operation. The speedy 
and unexpected death of the patient was not explained by 
the inspection. 

Case 8. — Trendelenburg, ' Verhandl. d. Deutsch. 
Gesellsch. f. Chirurgie, 1881, Bd. x, S. 60. — A man about 
80 years of age was admitted to a hospital with symptoms 
of hip-joint disease. For several years he had suffered 
from pain in the right hip ; there was a marked limp, 
fixation of the joint, and a discharging sinus. A swelling 
was detected upon the inner surface of the ilium, and per 
rectum a hard tumour could be felt upon the ischium, 
corresponding with the position of the acetabalum. These 
were regarded as pelvic abscesses, due to perforation of 
the bone by the disease in the hip. The joint was laid 
open, when to the surprise of the operator a small 
hydatid cyst escaped, and it was discovered that the right 
half of the bony pelvis was extensively invaded with 
hydatids. The acetabulum was converted into a cavity 
the size of the fist, bounded by osseous tissue, and occupied 



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362 HYDATIDS IN THE BONY FILYIS. 

by nuinerous cysts not larger than a pea. It also con- 
tained a sequestrum, the cancellous spaces of which were 
filled with cysts. The articular cartilage on the head of 
the femur was much less damaged than the duration of 
the disease would have suggested. The case was there- 
fore a primary hydatid infiltration of the bony pelvis with 
subsequent destruction of the hip-joint, giving rise to 
symptoms of hip disease. 

As regards treatment, the hydatids and sequestra were 
cleared away, and the upper end of the femur freely 
excised, so as to obtain good drainage. There was a 
profuse discharge of pus and hydatids, but after a time 
the wound closed. However, some months later it broke 
down; amputation was performed through the hip, and 
the patient sank a few hours after the operation. 

Case 9 (Pihan, 'Bull. Societe Anat.,' 1860, p. 268) .— 
A soldier aged 27 fell from his horse and was taken to a 
hospital for a severe bruise on the right hip and buttock. 
Although there were no signs of injury to the bones and 
articulation, yet after two months' rest in the hospital he 
could only get about with the help of a crutch, and there 
was constant pain in the hip-joint. 

When seen two and a half years after the accident, the 
right thigh was markedly flexed and adducted; the 
buttock was much swollen, painful on pressure, and 
yielded deep fluctuation ; movement at the hip very 
limited and acutely painful. Thus the symptoms resem- 
bled those of advanced hip disease with considerable 
shortening of the femur. An incision into the gluteal 
swelling evacuated an enormous quantity of sweet pus, 
and the subjacent bone was found to be bare. The 
abscess cavity was drained, but the patient gradually lost 
strength, developed hectic fever, and died about nine 
weeks after the operation. 

Autopsy. — The iliac portion of the os innominatum was 
occupied by a large cavity, produced by separation of the 
internal and external tables of the ilium to the extent of 



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BTDATIDS IN THS BONY FILYI8. 363 

6*5 cm. at its widest part^ with excavation of its can- 
cellous tissue. This cavity contained pus^ masses of 
hydatid cysts^ and sequestra of spongy bone^ some of 
which were an inch long. The walls of the cavity, adhe- 
rent to the adjacent soft tissues and supported by them, 
were exceedingly thin, and through perforations in them 
hydatids had escaped among the muscles of the pelvis 
and buttock. The acetabulum was so much destroyed 
that the upper end of the femur had penetrated into the 
pelvic cavity as far as the small trochanter, the head of 
the bone being almost worn away. Beside these lesions 
the sacro-iliac articulation was invaded, the front part of 
the first two sacral vertebras was destroyed, and there 
was a deep excavation in some of the lumbar vertebrae. 
All of these cavities were filled with hydatids, which 
extended through the sacral foramina into the erector 
spinse muscles on the back of the pelvis. The lumbar 
and sacral nerves were nowhere compressed, nor was the 
spinal canal invaded. On careful examination no hydatids 
were found in other parts of the body. 

Case 10 (Viertel, Archiv v. Langenbeck, 1875, p. 
487). — ^Woman aged 25 admitted to hospital. When 
twelve years old she fell upon the ice, and then felt 
severe pain in the right hip. However, she was able 
to rise after a few days and walk with the help of a stick. 
From that time there has always been more or less pain 
in the right thigh and hip. Two years before admission 
a second fall increased the pain and swelling about the 
hip, and the patient was compelled to take to her bed. 
Subsequently a painful tumour was observed in the right 
groin near the pubes, and a little later a fluctuating swell- 
ing formed at the anterior superior iliac spine. 

On admission (May 2nd) — The patient was in good 
health generally. The right leg was shortened (2 cm.), and 
the hip was abducted, rotated out, and flexed, with secon- 
dary lordosis and rigidity. Knee-joint normal, but upper 
part of thigh enlarged. There was a soft rounded tumour 



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864 HTDATID8 IK THE BONY PELVIS. 

at the inner third of the groin^ extending inwards to the 
labinm majus, outwards to the sheath of the vessels^ and 
measuring 12 cm. from above downwards. The tumour 
was crossed by Poupart's ligament, and appeared to spring 
from the body and horizontal ramus of the pubes. It was 
dull on percussion and distinctly fluctuating. A second 
fluctuating swelling near the anterior iliac spine measured 
6 cm. in diameter. By pressure it was completely reducible 
and the eroded edge of the ilium could be felt. The right 
iliac fossa was occupied by a large swellings which evidently 
communicated with those in the groin. An exploratory 
puncture gave no result because the cannula became blocked 
by a fragment of hydatid membrane. A fresh incision 
after a few days evacuated purulent fluid with scolices. 

May 13th. — Pains at back of right thigh and inflam- 
mation round the wound. 

18th. — Profuse suppuration had occurred. Fragments 
of bone and hydatid cysts discharged on the dressings. 

81st. — Well-marked pysemic symptoms. 

June 7th. — Several carious fetid sequestra removed 
from the large swelling in the iliac fossa. The tumour at 
the pubes was incised ; a litre of pus and small cysts 
evacuated. This cavity was situated between the abdo- 
minal wall and the thickened peritoneum. It extended to 
midway between symphysis and umbilicus^ and communi- 
cated with the larger external swelling in the iliac fossa. 

12th. — Patient gradually sank. 

Autopsy. — The right half of the pelvis was transformed 
into a membranous sac^ with thin bony plates in its walls 
which yielded crepitus on pressure. The acetabulum was 
destroyed^ and the altered upper end of the femur had 
passed into the pelvis as far as the first sacral vertebra. 
After maceration it was found that the ischium was intact^ 
but the horizontal ramus of the pubes was destroyed ; the 
head of the femur had disappeared^ and the remains of 
the ilium articulated with the top of the great trochanter. 
The lumbar spine was directed somewhat obliquely up- 
wards and to the left ; while the diseased right half of 



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HYDATIDS IN THE BONY PELVIS. 365 

the pelvis was so displaced that the highest point of its 
iliac crest was 3 cm. lower than that on the left side, 
and the symphysis pubis was displaced 2 cm. to the 
left. Hence the cavity of the true pelvis was contracted. 
Measurements were : — Diam. spin. = 25 cm. ; conj. vera 
= 10 cm. ; tranverse diameter of brim = 9 cm. ; between 
ischial spines it was only 6 cm. The membraDons sac 
above mentioned measured 12 cm. from before backwards^ 
and 9 cm. from side to side ; it extended in the direction 
of the horizontal ramus of the pubes as far as 2 cm. 
from the symphysis. By maceration the greater part of 
its wall was removed, especially the upper convex 
portion. What remained consisted of a semilunar osseous 
framework replacing the outer surface of the hip-bone ; 
it was smooth externally^ but rough and deeply grooved 
within. Below it the ischial spine and small sacro-sciatic 
notch were recognisable. Three adventitious articular 
surfaces had formed on different parts of the framework, 
and there were corresponding facets on the upper ex- 
tremity of the femur. 

The specimen, which has been preserved in the Breslau 
Museum, is represented in PI. VII, fig. 5. It consists of 
the pelvis, the last four lumbar vertebrae, and the upper 
ends of the femora. The articular facets on the pelvis are 
marked a. b. ; the corresponding surfaces on the right 
femur are similarly indicated. 

Case 11 (Reczey, 'Deutsche Zeitschrift f. Chir.,' 1876, 
Bd. vii, S. 285). — A woman aged 25 was admitted to a 
hospital for swellings in the right groin. Her illness 
begun four years previously with sharp pain about the 
right iliac crest, which was soon followed by a red tender 
swelling at that spot. Some weeks later a small lump 
appeared in the right gluteal region, and steadily enlarged. 
During the last twelve months a third tumour appeared 
on the outer surface of the right thigh, and likewise 
enlarged. 

On admission (October 11th). — The patient was strong, 



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366 HYDATIDS IN THE BONT PSLVI8. 

and in good health generally. A rounded tamour the size 
of an infant's head occupied the right buttock^ and 
extended across the sacrum to the middle line. Its sur- 
face was smooth^ and the tumour projected about 4 cm. 
above the level of the buttock. In the upper third of the 
thigh externally and behind the great trochanter a 
similar swelling existed. It was as large as a cocoa- 
nut, had an elevation of 5 cm., and was separated 
from the gluteal swelling by a shallow groove in the 
direction of the fold of the buttock. Downwards it ex- 
tended to the lower third of the thigh, and forwards to 
the groin. Two inches above the anterior superior iliac 
spine there was a third tumour, the size of the fist, which 
seemed to dip into the pelvis. These tumours were dis- 
tinctly fluctuant, and apparently communicated with each 
otber, but the skin covering them was normal, and there 
was no increase of temperature in the affected parts. A 
bony swelling connected with the inner surface of the ilium 
was also detected, and the adjacent region of the abdo- 
minal cavity was dull on percussion. There was no pain, 
and very little interference with walking. 

The patient at times suffered from pain in the region 
of the bladder with diflSculty in micturition, but the urine 
was normal, and there was nothing wrong with the pelvic 
viscera except a little utero-vaginal catarrh. Clini- 
cally the case was regarded as one of extensive suppura- 
tion due to chronic periostitis of the ilium. 

November 8th. — The gluteal swelling was punctured 
and drained, and a pint and a half of thick purulent fluid 
slowly escaped. Four days later hydatid cysts, the size 
of peas, were recognised in the discharge, and it was 
found that pressure on the iliac crest increased the flow. 
As the nature of the case was then clear, the swelling was 
freely incised, and many cysts were evacuated. 

From this time till her death the patient showed signs 
of chronic pyaemia, with occasional rigors, pains in joints, 
diarrhoea and wasting. Other swellings were incised, 
there was free suppuration, and an extensive bedsore 



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HYDATIDS IN THB BONY PELVIS. 367 

formed on the sacram. One month before death a spon- 
taneous fracture of the neck of the femur was discovered. 
Death occurred four and a half months after admission. 

Autopsy, — The right leg was shortened to the extent of 
five inches^ and markedly rotated outwards. Between the 
skin and fascia lata upon the front of the thigh there was 
a cavity containing brownish fluid, which communicated 
with a large intra-pelvic abscess along the ilio-psoas 
muscle. The two lamellae of the ilium were widely sepa- 
rated, and the space occupied by hydatid cysts the size of 
walnuts. So many perforations existed in the bone that 
it was represented by little more than a coarse framework. 
The acetabulum being destroyed, the head of the femur 
had penetrated deeply between the lamellse of the ilium^ 
and rested near the right first and second anterior sacral 
foramina. An excavation in the right half of the sacram 
contained hydatids mixed with pus and bony fragments. 
The head, neck, and upper third of shaft of femur were 
infiltrated with cysts, and were therefore spongy and 
brittle. A spontaneous fracture had taken place through 
the root of the neck, and the lower fragment of the femur 
was strongly drawn up on the outer side of the upper 
fragment. A hydatid cyst as large as an apple was found 
in the upper lobe of the right lung. 

Case 12 (Schwartz, ' Archives Generales,* 1884, i, 
p. 609). — A tradesman aged 42, who had been ill for four 
years, came under observation with a fluctuating swelling 
in the hollow of the groin. He had previously suffered 
from hip disease, ending in ankylosis. By puncture of 
the swelling some grumous pus was drawn ofF, and a free 
incision evacuated a large quantity of pus mixed with 
numerous small fragments of necrosed bone, which were 
derived from the ilium. The abscess cavity was found 
to extend downwards and inwards upon the inner surface 
of the ischium and pubes. The curette brought away 
very little. On the twentieth day after the operation 
five or six collapsed hydatid cysts escaped from the 



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HTDATIDS IN THS BONT FBLVIS. 

wound. The patient died of septioaamia on the thirty- 
eighth day. 

Autopsy, — It was foand that a large part of the os 
innominatum, together with the upper end of the femur, 
were almost completely destroyed. Suppuration had 
extended from the cavity which contained the hydatids 
into the groin, and had burst externally. The clinical 
diagnosis was abscess due to bone disease, and the exist- 
ence of hydatids was not suspected. When the discharge 
of cysts occurred the diagnosis was clear. 



B. Primary Hydatid Disease op Sacrum. 

Case 13 (Mazet, 'Bull. Soc. Anat.,' 1837, p. 226).— A 
man was admitted to a hospital for a chronic abscess 
situated over the posterior and superior spine of the 
ilium. An incision into the swelling liberated some 
excessively foul pus. Death ensued. There were ne 
paralytic symptoms during life. 

Autopsy. — It was found that the lower end of the 
vertebral caual and the whole length of the sacral canal 
were filled with hydatid cysts. The sacrum itself was 
carious, and its canal communicated with the abscess 
cavity by an opening situated in the posterior part of the 
bone near the middle line. The specimen is preserved 
in the Dupuytren Museum. 

Case 14 (Duplay et Morat, 'Archives de Medicine,*" 
1873, vol. iv, p. 558). — A woman aged 63 was admitted 
to a hospital tor a swelling upon the back of the sacrum 
which began seven years previously. It was situated at 
the upper end of the groove between the buttocks, some- 
what to the right of the middle line ; the swelling was 
soft, fluctuating, and about the size of the two fists» 
Fluctuation could also be detected in it by examination 
per rectum. At first the swelling had formed slowly, but 
two and a half years before admission it began to enlarge 



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HYDATIDS IN THE BONT PBLYIS. 369 

more rapidly^ causing severe sciatica. Gradaally the 
patient became paraplegic^ sensory and trophic lesions 
were developed^ and the lower extremities wasted and 
became drawn up. An exploratory incision into the 
swelling evacuated two litres of pus containing a large 
number of hydatid cysts. The surface of the sacrum 
was found to be bare^ and some irregular sequestra were 
removed by a second incision made obliquely a little 
below the tuber ischii. With the finger the outline of 
the abscess cavity could be traced towards the wall of 
the rectum^ as well as into the canal of the sacrum. 
After the operation rigors rapidly supervened, and the 
patient died on the fourth day. 

Autopsy. — Two collections of hydatids were found, the 
one outside and the other within the spinal canal, and 
there was a communication between them. The osseous 
walls of the space were thinned, and the sacral nerves 
compressed. 

Case 15 (Gangolphe et Polaillon, ' Kystes Hydatiques 
des Os,* 1886, p. 89). — ^A female glover, aged 33, was 
admitted to a hospital for a swelling in the sacral region. 
Her illness began four years previously with attacks of 
severe pain in the right leg and loin. About twelve months 
before admission a swelling formed over the back of the 
sacrum, and slowly enlarged until four days before admis- 
sion, when the patient fell downstairs and bruised her- 
self severely in the sacral region. After the accident the 
swelling rapidly enlarged. 

On admission there was a soft fluctuating tumour over 
the upper sacral vertebr», and encroaching upon the 
lumbar region. The skin over it was red and inflamed. 
The groove between the buttocks divided the lower part 
of the swelling into two lobes. Temperature normal; 
defascation often painful ; occasional difficulty in micturi- 
tion ; menses had always been irregular. By aspiration 
the nature of the swelling was determined. Accordingly 
two incisions were made, and a large quantity of thick pus. 



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370 HTDATID8 IK THE BONT PXLYIS. 

hydatid cysts^ and fragments of bone were evacaated. 
With the finger a large excavation in the sacmm was dis- 
covered. The wound was irrigated and drained. For 
seven weeks after the operation there was an abandant 
discharge of pus. The patient often had difficulty in mic- 
turition^ and sometimes pain in the hypogastrium and 
thigh ; bowels generally confined. On vaginal examina- 
tion the front of the sacrum was readily felt, and seemed 
to bulge forwards. The suppurating wounds were enlarged, 
and it was found that the finger could be passed through an 
irregular aperture in the middle of the sacrum as far as 
the soft parts of the pelvic cavity. Fragments of bone 
were readily detached from the margins of this perfora- 
tion, and many large sequestra were removed at subse- 
quent dressings of the wound. The cavity in the bone 
appeared to run forwards and to the left, towards the 
summit of the sacrum. The wound gradually closed about 
seven months after admission. Microscopical examination 
of the sequestra showed infiltration of the cancellous 
spaces with minute hydatid cysts, and some degree of 
rarefaction, but no inflammatory changes in the osseous 
tissue. 

c. Hydatids of Spine invading Pklvis. 

Case 16 (Wood, 'Australian Med, Journ.,' 1879, p. 
222). — A woman aged 45 was admitted to a hospital for 
rheumatic pains in legs and back, followed by incontin- 
ence of urine, paraplegia, and loss of sensation. Death 
from coma. 

Autopsy. — ^There was a hydatid cyst within the dura 
mater of the spinal cord opposite the last lumbar and upper 
three sacral vertebrae. It filled the spinal canal, and 
was prolonged through the second left anterior sacral 
foramen so as to form a bilocular swelling on the front of 
the sacrum, covering the exits of the second and third 
sacral nerves. There was another prolongation into the 
first foramen on the same side^ with the result that the 



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HYDATIDS IN THE BONY PELVIS. 871 

first and second left anterior sacral foramina were par* 
tially thrown into one large aperture. The entire cyst 
with its prolongations was filled with small daughter- 
cysts^ and it had been apparently ruptured within the 
spinal canal^ for there was a large quantity of fiuid and 
some free cysts within the membranes of the cord and 
brain. Embedded in the right lobe of the liver was a 
hydatid cyst four inches in diameter^ filled with secondary 
vesicles ; other viscera were normal. The cysts showed 
the characteristic lamination of the membranes, but no- 
scolices or booklets. 

Case 17 ('Guy's Hospital Reports/ vol. 1, p. 343). — 
A boy aged 17 died of severe cystitis and suppurative 
pyelonephritis. The body was much emaciated^ and 
there was an extensive slough over the back of the sacrum. 

Autopsy. — In the pelvic cavity there was a thick-walled 
cyst the size of a small apple, which was adherent to tha 
upper part of the sacrum, and had pushed the rectum 
aside and pressed upon the base of the bladder. This 
cyst contained from forty to fifty hydatids, varying in 
sisse from a pin's head to a small walnut, and its cavity 
communicated with the spinal canal through the first right 
anterior sacral foramen, which was enlarged to three times 
its normal dimensions. Within the canal the cysts had 
compressed the spinal membranes and cauda equina. 
With the exception of a small hydatid in the liver, the 
remaining viscera were normal. Farther dissection re- 
vealed distinct erosion of both anterior and posterior 
surfaces of the bodies of the first two sacral vertebrae, and 
superficial infiltration of the cancellons tissue with minute 
hydatids. The sac on the front of the sacrum was partly 
bounded by the eroded bone, and partly by a thick fibrous 
membrane ; it was crossed by branches of the right internal 
iliac vessels, and covered with peritoneum. 

Case 18 (Hontang, 'Bull. Soc. Anat.,' 1885, p. 95).— 



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872 HYDATIDS IN THB BONT PBLVIS. 

A woman aged 53 died of myelitis after an illness of 
five months' duration. 

Autopsy. — On the right side of the lumbar spine there 
was a large tumour extending from the last rib to the 
superior aperture of the pelvic cavity, and filling the right 
loin as well as the corresponding iliac fossa. It proved 
to be a hydatid cyst filled with fluid and many daughter- 
<;ysts, and was connected with a focus of hydatid disease 
in the substance of the lumbar vertebrae. 



D. Hydatids of Fbmub invading Pelvis. 

Cask 19 (Schnitzler, 'Intemat. klin. Rundschau./ 
1892, S. 1138).— A man aged 28 was admitted to a hos- 
pital for large swellings in the groin, thigh, and buttock. 
His illness began when ten years old with a swelling in 
the left groin, which was thought to be due to hip 
disease. Fluctuating tumours subsequently formed in 
other parts of the thigh, and very slowly enlarged. One 
of these ultimately burst, and gave vent to a large quan- 
tity of brownish fluid. During the whole of his illness 
the patient could walk with the help of a stick, and 
suffered very little pain. The swellings were freely 
incised and drained, but the patient gradually sank from 
exhaustion. 

Autopsy. — Very extensive destruction of the upper 
two thirds of the femur was found, and the disease had 
extended to the ilium and horizontal ramus of the pnbes 
around the acetabulum. Large suppurating cavities 
existed in the left iliac fossa beneath the peritoneum, 
and extended towards the pubes. These contained 
foetid pus and cysts. In the hollow of the sacrum along- 
side of the rectum there was a thin-walled sac containing 
many hydatids about the size of a pea. 

Case 20 {' Guy's Hospital Reports,' vol. 1, p. 334).— A 
greengrocer aged 38 was admitted for large swellings in 



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HYDATIDS IN THE BOMT PELVIS. 873 

the thigh and groin. Incisions evacuated much brown 
pus mingled with hydatid cysts. A sequestrum repre- 
senting a part of the head of the femur was removed^ and 
a perforation was then discovered in the acetabulum. 
The wall of the pelvis felt very friable. Ankylosis of 
the hip eventually took place with shortening of the limb 
to the extent of nearly three inches. 



VOL, XXXVI. 2ft 



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374 



A CASE OF PRIMARY CARCINOMA OP THE 
BODY OP THE UTERUS IN WHICH VAGINAL 
HYSTERECTOMY WAS PERFORMED, AND 
MORE THAN TWO YEARS HAVE ELAPSED 
WITHOUT RECURRENCE; WITH A TABLE 
OP FIVE OTHER CASES OP VAGINAL HYS- 
TERECTOMY FOR CANCER OF THE BODY 
OP THE UTERUS. 

By Abthub H. N. Lewebs, M.D.Lond., 

OB8TBTBI0 PHYSXOIAIT TO THB LOHDOV HOSPITAL. 

(Received September 29th, 1894.) 
{Abstract.) 

Thb author records a case of primary carcinoma of the body 
of the uterus in a patient 44 years of age. Vaginal hysterec- 
tomy was performed on the 17th of March, 1892. The patient 
made a good recovery from the operation, and has remained 
under the author's observation, so that he has examined her 
from time to time. She has remained in good health, and 
there was no sign of recurrence when she was last examined on 
November 1st, 1894. Attention is dii-ected to the possibility 
of early cases of cancer of the body being mistaken for uterine 
fibroid. The shorter duration of the symptoms in cancer of 
the body will generally, at least, justify further investigation 
by dilatation of the cervix. As regards the operation itself, 
attention is called to the difficulty of getting the uterus out, 
even when it is partially or completely separated, where it is as 
large as that in the present case. 

In Case 6 in the table this difficulty was overcome by 
applying a pair of forceps similar to small midwifery forceps. 



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PBIMABT CASOINOKA Of THE BODY OV THB UTSBUS. 875 

The author prefers pressure forceps to ligatures for securiDg 
the broad ligaments. Ligatures, however, were used in the 
first two cases in the table, and pressure-forceps in the re- 
maining cases. 

For a case such as that here fully recorded to have any 
scientific value as bearing on the amenability of cancer of the 
body of the uterus to operative treatment, two conditions are 
essential : first, the exhibition of the specimen and of sections 
of it, so that independent observation may corroborate the 
author's opinion as to the nature of the growth ; and secondly, 
that the patient should come regularly to be examined, as she 
fortunately has done in this case. 

The author gives reasons for thinking that primary cancer of 
the body of the uterus may be a more chronic disease than 
cancer of the cervix. As regards clinical varieties, be has met 
with two. In one set of cases the growth is soft, friable, and 
easily broken down with the finger. In the other set of cases 
there is merely a hard, irregular, perhaps ulcerated condition 
found in the endometrium; in these cases nothing can he 
detached with the finger or curette. 

A table of the six cases in which the author has performed 
vaginal hysterectomy for primary cancer of the body of the 
uterus is appended. There was no mortality from the opera- 
tion. The subsequent history is briefly indicated in the table. 

J. T — , aged 44, was admitted into the London Hos- 
pital under my care on February 24th, 1892. 

Premcma history, — Till about a year ago she always 
lived comfortably, and had plenty to eat and drink. As 
regards stimulants, she has only taken a glass of beer 
occasionally. She was in service before she married. 
She has been married twice; the first time when she was 
thirty-four, and the second time when she was forty-three. 
She has never had any children or miscarriages. 

The catamenia appeared when she was twenty, and she 
has been regular every three weeks ; the periods lasted 
a week^ and she lost a full quantity each time. She had 
no pain or discomfort at her periods till six or seven 
years ago. 



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876 FBIMABT OABCINOMA OF THE BODY OF THI UTERUS. 

Family hisiory. — Her father died of ''old age;" she 
does not know the cause of her mother's death. She 
had one brother who^ when last she heard of him^ was 
not in his right mind. 

History of the present illness, — She was quite well till 
about seven years ago. Aboat that time she began to 
have pain in the right groin^ going round to the back at 
the menstraal periods. She had then no pain whatever 
between the periods, and apparently, till at all events the 
last few months, her general health seems to have been 
fairly good. She herself only dates her illness from 
Christmas, 1891, that is about two months only before her 
admission to the hospital. Up till Christmas last she 
had continued to menstruate regularly every three weeks, 
and had no pain between the periods, nor was there any 
intermenstrual discharge till then. Since Christmas, 
1891, she has not had any severe pain, but there has been 
an almost constant red vaginal discharge between the 
periods. Since then a week is the longest time she has 
gone without seeing some red discharge. She has lost 
flesh considerably, but the appetite has been good, and 
she has been able to sleep well. During the last three 
weeks she has found a difficulty in holding her water 
when lying quiet in bed. There has been no offensive 
vaginal discharge. 

State on admission, — The patient was very markedly 
anaemic, her expression somewhat anxious, and her 
general condition feeble. There was no evidence of any 
organic disease in the chest, bat there was a loud sys- 
tolic murmur, best heard at the base, and seemed suffi- 
ciently accounted for by the extreme anaemia. The heart's 
apex-beat was in the normal position. The pulse was 
84. The urine was normal. 

March 1st. — ^The following note was made : — " No 
distinct swelling can be felt in the hypogastric region on 
simple abdominal examination. On bimanual examination 
the uterus is considerably enlarged, and in a position of 
anteversion. The external os is rather patulous, and 



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FBIMABT CABCINOMiL OF THE BODT OF THB UTBBUB* 877 

there is a small macons polypus attached jnst within it. 
The sound passed 3^ inches. The discharge from the 
OS uteri is sanious but not offensive/' 

At this time my opinion was that the case was pro* 
bably one of uterine fibroid. On further consideration, 
however^ and taking into account that although she had 
suffered from dysmenorrhoea for six or seven years her 
illness had begun somewhat acutely, and had only lasted 
some two or three months, and having in mind that she 
was at the time of admission much more anaemic than is 
commonly the case in patients with uterine fibroids of 
only a few months' duration, it seemed to me that the case 
called for further investigation, and accordingly I decided 
to dilate the cervix and explore the endometrium. 

On March the 9th I inserted three laminaria tents, and 
on the next day examined the patient under ether. After 
removing the tents the finger passed easily into the 
uterus, and found an extensive, soft, brittle growth on 
the posterior surface of the endometrium, chiefly to the 
right of the middle line. Yellowish-white pieces of the 
growth came away as the finger was withdrawn. The 
uterus was freely moveable, and there was no evidence of 
extension either to the broad ligaments, or the utero- 
sacral ligaments. The discharge on the examining finger 
that had been passed into the uterus was not in the least 
offensive. 

The result of the examination satisfied me that the 
case was one of primary malignant disease of the body of 
the uterus ; and the subsequent microscopic examination 
of the specimen fully confirmed this view, the growth 
being a typical carcinoma. The patient readily consented 
to operation, and accordingly I proceeded to remove the 
uterus on March 17th, 1892, at 2 p.m. 

Note on the operation. — In the morning, and again at 
midday, a vaginal douche of 1 — 1000 corrosive sublimate 
solution was given. The patient was anaesthetised with 
the A. C. E. mixture. A vaginal douche of 1 — 1000 
sublimate lotion was given, and the cervix drawn down to 



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S78 PBIICABY CABOINOVA OF THE BODY OF THB UTEBUB. 

the orifice of the vulva with two volsellse. The anterior 
fornix was incised firsts then the posterior^ and then the 
ends of these incisions were joined laterally. The bladder 
was easily separated as high as the vesico-uterine pouch. 
Douglas's poach was then opened. The lateral attach- 
ments of the cervix were clamped, and the cervix thus 
cleared as high as the level of the internal os uteri. The 
vesico-nterine pouch of peritoneum was then opened. So 
far no difficulty had been met with. Examining now 
with one finger in Douglas's pouch and one anteriorly, it 
became evident that there would be great difficulty iu 
getting the uterus out on account of its size. At one 
time I thought of overcoming this difficulty by splitting 
the uterus into two halves, as has been done by various 
operators. When I had done so as far as the upper limit 
of the cervix there seemed to me to be gi*eat risk in 
continuing to divide the uterus for fear of injuring 
adjacent structures, and I gave up the attempt. At last, 
by exercising very strong traction on the uterus towards 
the left, I was able to get my finger above the right 
broad ligament. This I clamped outside the ovary, and 
divided it. By steady pulling the right side of the uterus 
was gradually brought into view, and then the fundus. 
The uterus was now only attached by the left broad liga- 
ment ; this was easily clamped between the uterus and 
the ovary. The broad ligament was then divided and 
the uterus removed. A cyst the size of half a walnut 
was met with in the left broad ligament ; it was punctured, 
and a little clear fluid came out of it. A douche of iodine 
water (gj Tr.Iodi to the pint of water) was then given, some 
of it passing well into Douglas's pouch. There were four 
pairs of large pressure forceps left on, and two pairs of 
small forceps. Dry carbolic gauze was packed into the 
vagina, a T- bandage was put on, and the patient put into 
bed. It should have been mentioned that, owing to the 
narrowness of the vagina, it was found necessary to get 
additional room by incising the posterior vaginal wall and 
perinsBum. The operation lasted one hour and ten minutes. 



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PBIXABT CARCINOMA OV THB BODY OV THB UTBBUS. 879 

SiibseqiAent progress. — ^The patient made an uninter- 
rupted recovery. She was several times sick during the 
first forty-eight hours after the operation ; the last occa- 
sion on which she vomited being at 12 noon on the 19th 
of March, the second day. The gauze plug was taken 
out on the morning of the 18th, and the pressure forceps 
were removed at 5 p.m. on the 19th. After the removal 
of the forceps douches of weak iodine water were given 
every six hours for several days. 

As regards the pulse and temperature, the tempe- 
rature on the evening of the day after the operation, the 
18th of March, was 99*4° ; on the 19th the pulse was 100, 
and the tempei*ature 99'8^. The temperature was about 
100^, and not above 100*2®, for seven days after the 
operation. On the evening of the seventh day it was 101®, 
and on that of the ninth day 102'2®, which was the highest 
temperature recorded. On the tenth day the temperature 
was 100^, and on the eleventh 98® in the morning. After 
that day there was no rise above 100^. It will be noticed 
that the highest temperature occurred about the time 
when the sloughs in the neighbourhood of the wound 
might be expected to be separating. 

On April 7th she had some pain in the region of the 
anus and vagina, but the temperature was only 100®, and 
the pulse 80. She was examined on this date, and the 
following note made : 

'^ At the upper part of the vagina there is a cavity 
the size of a halfpenny, and about half to three quarters 
of an inch deep. It has the appearance of a healthy 
granulating wound. The abdomen is flaccid, and not 
tender." 

On April 14th she was examined ag^in, and the raw 
surface at the top of the vagina was then only the size 
of sixpence. 

On May 5th the wound was found to be healed, except 
a little granulation the size of a pea. 

On May 19th the wound was soundly healed. 

Note on the weight. — On March 2nd, i. e. before the 



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880 PBDCABT OABOINOMA OF THS BODY OF THE UTSBU8. 

operation^ the patient weighed 7 st. and i lb. ; on April 
21st, 6 St. 12 lbs. ; and on May 11th, 7 st. 7 lbs. 

The patient has come to see me at the London Hospital 
at intervals of a few weeks ever since the operation np 
to the present time, and from time to time she has been 
weighed, and I have examined her. There has been no 
sign of recnrrence. The last time I examined her was 
in September, 1894, two years and a half since the 
operation. 

Note on the specimen. — It was measured and weighed 
after being two years in spirit. The extreme length is 
4^ inches, and the thickness from before back 2^ inches. 
The breadth from side to side coald not be well measured 
after the uterus had been opened and hardened. The 
weight of the uterus is 6 oz. Microscopically the growth 
is a columnar-celled carcinoma. 

Remarks. — In all cases where long periods have elapsed 
after operations for malignant growths without recurrence 
it is essential, in order that any such case may have scien- 
tific value, first, that the growth should be proved beyond 
doubt to be malignant, — as, for example, by submitting it 
to the examination of independent observers ; and second, 
that opportunity should be afforded of keeping the patient 
under observation. The specimen (and a section of it) from 
the case just recorded were exhibited at the Obstetrical 
Society of London some two years ago,'*^ and have also been 
seen by many other observers privately, among whom I 
may mention Sir John Williams, and every one who has 
examined it has agreed that it is a carcinoma of the body 
of the uterus. As regards the other condition, it has 
fortunately happened that the patient has come to see me 
regularly at the London Hospital, and up to the present 
time has remained quite well. 

Looking over the history of the case, it will be observed 
that as regards age she was rather younger than most of 
the cases of primary carcinoma of the body of the uterus, 
as most patients with this disease are over fifty years of 

• ' Obstet. TnuiB.,' vol. xxxiy, p. 218. 



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PBIVABY CARCINOMA OF THlfi BODY OF THE UTBBUB. 881 

age, while the patient was only forty-foar. As regards 
symptoms, pain was not a marked feature, but it is worth 
noticing that for seven years before the commencement of 
this illness she had dysmenorrhoea, and that ap till then 
she had suffered from no pain at her periods. As regards 
fertility t this patient was sterile ; and the fact that she had 
been twice married makes it almost certain that the 
sterility was on her side. 

As regards diagnosis, it will be evident on looking at the 
history that there are many points in common between 
carcinoma of the body of the uterus and fibroid tumour 
of the uterus. Thus sterility, a dysmenorrhcea com- 
mencing in adult life, metrorrhagia, marked anasmia, a 
normal condition of the vaginal portion of the cervix and 
a considerable enlargement of the body of the uterus are 
all features equally presented in many cases of uterine 
fibroid. As a rule, the fact that carcinoma of the body 
of the uterus occurs after the menopause would readily 
serve to exclude fibroid tumour of the uterus ; but when the 
disease occurs under fifty, as in this case, the age will not 
help the diagnosis. At first, for a few days, I was myself 
inclined to regard the case as one of fibroid tumour ; but 
when a careful inquiry was made as to the duration of the 
symptoms, it appeared to me that the patient was, speaking 
generally, in a much worse condition than would be 
accounted for by the presence of fibroid tumour of the 
uterus for only three months or thereabouts ; and fortu- 
nately I determined on dilating the cervix, when the 
discovery of a soft, friable, papillary growth made the 
nature of the case at once evident. 

As regards the operation, the mechanical difficulty of 
getting the uterus out was very considerable. I do not 
use ligatures in extirpating the uterus per vaginam ; and 
I do not myself see how, working in a narrow space 
with so large a uterus as that in this case, one could 
feel confident that the vessels were securely tied. With 
a small uterus the broad ligaments can be securely tied, 
and no doubt they can be sometimes also when the 



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382 PBDfABY CARCINOMA OF THE BODY OF THS UTSBUB. 

ntems is as large as in this case. I used ligatures 
myself in a case where the uteras was of about the same 
size^ a case I hare recorded previously in the Obstetrical 
* Transactions/ 'i^ but I think the risk of ligatures coming 
off or getting loose in such cases is very considerable^ 
and I prefer to trust entirely to pressure forceps. It is said 
that there is a greater risk of secondary hsBmorrhage 
when pressure forceps have been used^ but I have never 
had this occur^ though I am quite alive to the fact that 
pressure forceps have their disadvantages. 

The case just recorded was the third in which I have 
removed the whole uterus per vaginam for carcinoma of 
the body. Altogether I have had six cases of extir- 
pation for carcinoma of the body. In all the six the 
patients recovered from the operation. Case 1 was fully 
recorded in the Obstetrical Society's 'Transactions/f Case 
2 was recorded in the ' Lancet/ j; and is tlie only one of the 
six in which I cannot produce absolute proof that the case 
was one of carcinoma. I may briefly say that in that 
case a polypoid cauliflower-like mass^ exactly to all 
appearance resembling the ordinary cauliflower growth 
of the cervix, projected through a dilated os uteri. I 
removed the mass, which came away in pieces as does the 
ordinary cauliflower growth, unfortunately keeping none 
of the mass, aR I relied on finding plenty of it when I 
should subsequently extirpate the uterus. When I extir- 
pated the uterus, however, I could not find any of the 
growth, though there was a depressed excavated area 
presumably the situation where the polypoid mass had 
been attached. Case 3 is the one fully recorded in this 
paper. In Cases 4, 5, and 6 the proof of malignancy is 
complete, and I have the specimens and sections; but two 
years have not yet elapsed since the operation in these 
cases, and I reserve the full record of them for another 
occasion. A short table of these six cases is appended. 

* Case 1 in tbe table. 

t Vol. XXX, for 1888, p. 218. 

J « Lancet,' 1893. vol. i, p. 1379. 



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884 PKIICABT CARCINOMA OF THE BODY Of THE UTSBUB. 

Dr. Lewers showed the specimens corresponding to 
cases nnmbered 8^ 4^ 5, and 6 in the table ; and sections 
of each of these specimens were also exhibited nnder the 
microscope. 

CUnical varieties, — A word or two may be said as to 
the clinical varieties of cancer of the body of the ntems. 
As far as my own experience goes there are two kinds of 
growth. In one set of cases the growth is papillary^ soft^ 
and easily broken down, so that pieces are readily 
detached with the finger. In the other set of cases the 
growth is hard, and nothing can be detached, either with 
the finger or curette. In both sets of cases the history 
and symptoms are similar; there is enlargement of the 
body of the aterns, and free bleeding follows the passage 
of the sound, no matter how gently it may be used. This 
is a very suggestive sign, and should, I think, always 
lead to a further investigation. In the cases where the 
growth is hard, one cannot feel the same certainty as 
regards the diagnosis as when the growth is of the soft 
variety. The examining finger finds a hard, irregular, 
perhaps ulcerated condition of the endometrium that 
cannot be classified with any non-malignant condition 
with which we are familiar. The microscopical appear- 
ances are equally typical of carcinoma in the hard as in 
the soft variety. In four of the six cases tabulated the 
growth was of the soft variety, in the remaining two it 
was hard. 

In addition to the cases mentioned in the table I have, 
speaking from memory, seen altogether five other cases, 
in my own practice, of cancer of the body of the uterus 
in which, either because the disease was too far advanced, 
or because the patient refused to have anything done, I 
did not operate. In four of the five I think the growth 
was soft, in the other hard. The history of some of those 
cases that were not operated on, as well as the history in 
some ol the six cases which I have here tabulated, gives 
me an impression that cancer of the body of the uterus 



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PBIMABT CiLRCINOMA OF THE BODY OF THE UTEBUS. 885 

may be a more chronic disease than cancer of the cervix. 
Quite recently I heard of a case (one of the five mentioned 
in which no operation was performed) that was sent to see 
me in September, 1891, by Dr. Skyrme, of Cardiff. The 
patient is only now, September, 1894, actually in ex- 
tremis. The symptoms had lasted nearly a year when I 
first saw her. It will be seen that of the eleven cases of 
cancer of the body of the uterus here referred to, in six 
of them the uterus was removed, and in two of the re- 
maining five the patients refused to allow an operation. 
That is, in eight out of eleven cases an operation seemed 
desirable when the cases first came under my observation. 
If one compares this result with similar cases of cancer of 
the cervix, I cannot speak from actual figures, not having 
kept a record of cases too far advanced for operation^ but 
I have only performed thirty-eight radical operations for 
cancer of the cervix ; of these twenty-five were supra- 
vaginal amputations of the cervix, and the remaining 
thirteen were total extirpations ; but altogether I must 
have seen several hundred cases of cancer of the cervix 
too far advanced for any operation to be advisable. This, 
then, to some extent bears out the impression I have 
mentioned, namely, that cases of carcinoma of the body of 
the uterus tend to run a more chronic course than those 
of cancer of the cervix ; but it is difficult to obtain the 
data necessary for a definite conclusion on this point. 



Dr. Pbteb Hobbocks hoped for the time when cancer might 
be cured by less repulsive means than the knife. It must be 
admitted that the Imife was the best treatment at our disposal 
to-day, and hence progress had been made since the days of Sir 
Benjamin Brodie, who used this method of treatment very 
largely for cancer, more especially of the breast. At the end of 
his life he said he was doubtful whether the operations had 
prolonged life or not. Nevertheless all must admit that exci- 
sion, when performed early enough, was the best thing to be 
done, and so it was very important to know how best to do it. 
He noted that the author of the paper stated that when a 
uterine soimd was passed it invariably caused profuse hfldmor- 
rhage when cancer was present in the body. He related 



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986 PRIMABT CARCINOMA OV THB BODY OF THE UTSBU8. 

|>articalar8 of a case of bis colleague's in which the passage of a 
uterine sound caused no hsBmorrbage worth mentioning, and yet 
it was subsequently discovered that there was extensive malig- 
nant growth in the walls of the cavity of the uterus. No doubt 
this was an exceptional case, but it ought not to go forth that 
unless profuse hsemorrhage results on the passing of a sound, 
therefore malignant disease is not present. Again, in re- 
gard to the pain, he was disposed to agree with the author 
that the severity of the pain was not so great on the average in 
cases of cancer of the body as in cases of cancer of the neck of 
the womb. He had hitherto preferred to use ligatures to tie 
the broad ligaments rather than forceps ; but inasmuch as the 
latter so materially lessened the time of the operation, and, 
moreover, as they had been so successful in the bands of the 
■author, he felt disposed to try them again. He pointed out 
how the handles got in the way, and how difficult it was to 
avoid moving them with the risk of tearing the tissues held by 
the blades, or dragging the latter off the parts held. Also he 
asked if the author used any particidar form of forceps, as it 
was difficult to get a pair that would grasp equally from heel to 
tip of the blades. In some cases where the uterus was very 
large it was necessary to open the abdomen, fix a serre-noeud 
low down, and remove the part above ; then close the abdomen 
and remove the piece of cervix and serre-noeud per vagituim. 
He mentioned two cases in which this had been done — one by 
his colleague, the patient recovering, and the other by himself, 
in which the growth was so large that it was impossible to 
remove even the remaining portion per vaginam, and the whole 
of it had to be removed by the abdomen: this patient suc- 
cumbed. 

Dr. Amand Bouth complimented Dr. Lewers on his paper 
and on his success. He had, when he first began to do vaginal 
hysterectomy, used forceps for securing the broad ligaments, 
because they shortened the duration of the operation, thus 
lessening shock, and because one could tell with more exactness 
the point up to which the ligament could be divided, which one 
could not always do with silk sutures. He had soon found, 
however, that the convalescing stage, when forceps had been 
used, was not nearly so satisfactory as after ligaturing. The 
forceps go some way up into the peritoneal cavity, and are in a 
few hours surrounded by lymph, and when the forceps were 
removed at the end of thirty-six or forty-eight hours, spaces 
were left containing a piece of broad ligament which sloughs 
and comes away by suppuration in about ten or eleven days, 
during which time there is some exhaustion and pyrexia, 
ranging often to 102^ F., and occasional pocketing of pus. The 
forceps, moreover, take up much room, especially in cases where 
the uterus is large, as they have to be put on obliquely. 



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PSIMABT CABCINOMA OF THE BODY OF THB UTESU8. 887 

Latterly, therefore, he had used ligatures only, and the tempe- 
rature rarely rose to 100^ F., and the patient was practically 
convalescent about the third day. He would like to know 
what was Dr. Lewers's practice as regards removing the ovaries 
in these cases. In women of fifty and sixty it did not much 
matter whether they were removed or not, but it was thought 
hy some that in yoxmger women it was advanti^eous to do so. 

Mr. Malcolm said he bad been asked by Mr. Knowsley 
Thornton to mention two cases operated on by him— one in 
July, 1885, and one in July, 1889. Both were now quite well, 
more than nine and five years after the operations. The first 
was between forty-five and fifty years of age, and the age of the 
second was twenty-eight. Both were diagnosed by scraping, and 
microscopic examination of the parts removed, and in both 
cases the cancerous nature of the disease was verified by micro- 
scopic examination after removal. Both cases were treated in 
association with the late Dr. Matthews Duncan. The first of 
these cases showed a hard tumour, about the size of a hazel-nut, 
situated in the centre of the fundus of the uterus close to its 
mucous membrane, which was here destroyed. The growth 
resembled a scirrbus of the breast, with trabeculss extending in 
all directions, but in no case passing beyond the uterine sub- 
stance. The operation was rendered difficult bj the presence 
of a subperitoneal fibroid, about one inch in diameter, on the 
inner part of the left broad ligament. Ligatures were used to 
arrest the hsemorrhage, and no forceps were left in the vagina, 
which was packed with iodoform gauze, and there was no 
trouble during convalescence. Mr. Malcolm regretted that he 
could not remember any details of the second case. 

Mr. Alban Doban concluded, after a study of Dr. Lewers's 
and Professor Kaltenbach's statistics, that vaginal hysterectomy 
for cancer was justifiable, and that cancer of tiie uterus was less 
malignant than cancer of the breast. Many surgeons, arguing 
a priori, insisted that vaginal hysterectomy was bad surgery, as 
it was impossible to cut freely beyond the limits of the cancer. 
In operating for cancer of the breast many authorities adopted 
very radical measures, excising the pectoralis major muscle and 
all the fat around the breast as high as the clavicle and far up 
the axilla reaching to the vein. Tet the cancer, nevertheless, 
recurred in many patients. On the other hand, recurrence was 
hardly, if at all, more frequent after vaginal hysterectomy, where 
the knife was, of necessity, made to pass very close to the limits 
of the malignant deposit. 

Dr. Griffith, while complimenting Dr. Lowers on the 
success of his cases and the value of his contributions to the 
subject, desired to appeal to him to classify his cases according 
to the existing stanoard of pathological classification. Why 
should gynsBcologists alone be content to use the terms hard 



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888 FBIMABT CABCnrOMA OF THE BODY OF THE UTEBUS. 

and soft for cancer of the body of the uterus, and cauliflower 
and mushroom, &c., for cancers of the cervix — terms which have 
a certain clinical value indeed, but convey no accurate idea of 
the varieties of the disease ? Dr. Griffith also referred to the 
great difficulty that there often is in the diagnosis of cancer of 
the body in its early stages, more particularly perhaps in dis- 
tinguishing malignant from simple adenoma of the mucous 
membrane. 

The Pbbsidbnt thought that Dr. Lewers was to be congratu- 
lated on the reception his paper had met with and the discussion 
it had elicited. He (the President) thought that in the treat- 
ment of cancer we had advanced veiy far beyond the position 
during the life of Sir Benjamin Brodie, for it was beyond doubt 
that the removal of cancer of the uterus did often prolong life. 
There was a good reason why better results should follow 
removal of uterine cancer than removal of cancer in other parts ; 
for uterine cancer was less often accompanied with secondary 
growths in other parts than any other kind of cancer. The 
decrease in the mortality of this operation was very gratifying. 
When the Society last discussed this question in 1885, the 
mortality was shown to be about 28 per cent. In a recent paper 
by Buecheler (' Zeit. f. Geb. und Gyn.,' Band xxx) was a table 
embracing nearly 800 cases by different German operators, and 
showing an average mortality of about 10 per cent., while of 159 
cases operated on by the late Prof. Kaltenbach the mortality was 
only between 3 and 4 per cent. He (the President) saw no 
reason why the mortality should not be still further reduced ; 
for in well-selected cases, in which the disease was early, the 
operator had to deal with parts unaltered by disease, and the 
best way of proceeding could be reduced to rule ; there were in 
this operation none of the manifold difficulties attending the 
removal of large tumours and inflamed parts. In Prof. 
Kaltenbach's cases the proportion of those going three years 
and upwards without recurrence was 25 per cent., and other 
statistics showed as large a proportion. The question of 
ligature versus forceps was a very important one. By using 
ligatures the removal of the uterine appendages was possible. 
This had two advantages. First, in cancer there was sometimes 
pvosalpinx, and cancer of the uterine body sometimes spread 
along the Fallopian tubes. In such cases there was an undeni- 
able advantage in removing the tubes. But in cases suitable 
for operation such disease of the tubes was not common. 
Second, it was said that when the uterine appendages were left 
pelvic pain and troublesome moliminal symptoms occurred. 
He (the President) did not remember that in the cases in which 
he had removed the uterus and left the appendages there had 
been much complaint of the kind, but he thought t£e experience 
of operators was wanted as to the frequency and severity of such 



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PRIMARY CARCINOMA OP THE BODY OP THE UTERUS. 889 

symptoms. Prof. Kaltenbacli made a point of suturing the 
peritoneum. By this any prolapse of bowel or omentum was 
prevented. He (the President) had had one case in which a 
piece of omentum came down after the operation, became 
adherent in the wound, and sloughed off. The patient did well, 
but it was an accident which it was desirable to prevent. He 
(the President) could confirm, from his own experience, Dr. 
Lewers's statement that there were cases of cancer of the body 
of uterus in which nothing could be detached with finger or 
curette ; in these cases the diagnosis had to be made without 
the help of the microscope. Dr. Lewers's classification of 
cases of cancer of the uterine body into hard and soft, although 
perhaps clinically useful, yet did not exhaust all the varieties of 
this disease. 

Dr. Lewbrs, in reply, said that the case cited by Dr. Horrocks 
in which no hemorrhage followed the passing of the sound was 
very interesting ; but still it was true that in the large majority 
of cases of cancer of the body of the uterus rather free bleeding 
occurred, no matter how gently the sound was passed ; also in 
the majority of the cases pain was an early and marked sym- 
ptom ; exceptionally, as in the case fully recorded in his paper, 
pain was not conspicuous. While every one would welcome any 
means of treating cancer effectually without operation, it could 
not be eontest-ed that at present the only hope for the patient 
lay in early diagnosis and free removal of the diseased tissue. 
He thought there could be no question that when cases for 
operation were carefully selected .life was prolonged by the 
operation. In the case in question the patient was at the 
present time in perfect health, though it was nearly three years 
since the uterus had been removed. As regards the diagnosis 
of cancer of the body of the uterus, it was generally easy when 
all the circumstances of the case were taken into account. He 
deprecated a hesitating footing, which often meant that a dia- 
gnosis was not arrived at till the case had become too far 
advanced for operation. Mr. Doran had compare4 cancer of 
the breast with cancer of the uterus. Dr. Lewers believed that, 
so far as cancer of the body of the uterus was concerned, at all 
events, the disease remained for a longer time strictly circum- 
scribed, and therefore more amenable to treatment than in cases 
of cancer of the breast. Reference had been made to vaginal 
hysterectomies for cancer by other operators, but he believed 
that in most of the cases cited the operation had been under- 
taken for cancer of the cervix, and therefore such cases were in 
a different class altogether from those mentioned in his (Dr. 
liewers's) paper, which dealt with hysterectomies for cancer of 
the body of the uterus. Dr. Horrocks had referred to a case 
where tne uterus was too large to remove per va^inam, and 
where, therefore, the combined abdominal and vaginal operation 
VOL. XXXVI. 27 



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300 PBIHAfiY OABCINOKA OV THE BODY OV THIB UTIBUS. 

had been employed. On tliis point Dr. Lewers believed that^ 
speaking generallj, by the time the uterus bad become so large 
tnat it could not be removed 'per vaginam the disease had 
involved tissues external to the uterus, and that therefore, as 
the chance of cure was almost nil, the operation was not worth 
undertaking. His classification of cases into those of hard and 
soft cancer had been criticised ; it was not meant as a patho^ 
logical classification, but merely as one that was certainly useful 
clinically ; the hard form was much the rarer, and might easily 
be overlooked unless its existence was remembered, and the 
fact that in such cases nothing could be removed with the 
finger or curette borne in mind. As regards the details of the 
operation, here, again, Dr. Lewers dwelt on the importance of 
distinguishing cases of hysterectomy for cancer of the cervix 
from those of cancer of the body. In the former class the 
operation might often, as had been said by some of the speakers, 
present no great difficultv ; but it was far otherwise in hyster- 
ectomy for cancer of the body. The patient was frequently old» 
and there was, therefore, senile narrowing of the vagina, and 
she was often also nulliparous. The body of the uterus waa 
considerably enlarged. On the other hand, in hysterectomy for 
cancer of the cervix the body of the uterus was generally small,^ 
and the vagina usually capacious. Dr. Lewers had not gene- 
rally removed the uterine appendages in performing hysterec- 
tomy for cancer, and had not traced any after trouble to having 
so left them. He thought that it was best to trust to pressure 
forceps for securing the broad ligaments, and that it waa 
dangerous to remove them too soon, not only for fear of hsBmor- 
rhage, but owing to the risk of breaking down the delicate 
adhesions in the neighbourhood of the wound. Dr. Lewers 
thanked the Society for the attention it had given to his paper. 



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INDEX. 



PAGX 

Abdominal section, fibro-cystic tumour of the uterus removed 

by (A. H. N. Lewers) . . .270 

wall, abscess in (R. J. Probyn-WiUiams) . . 62 

Abortion, incomplete tubal (L. Bemfry) . . . 261 
Abscess in abdominal wall (B. J. Pipbyn- Williams) . . 62 
of the ovary, three cases of pelvic inflammation attended 

with (0. J. CuUingworth) . . . .277 

Acephalous, acardiac foetus (G. E. Herman) . . 65 

Address (Annual) of the President, G. Ernest Herman, M.B., 

February 7th, 1894 . . . .75 

Adenoma of the portio vaginalis uteri, forming a depressed 

sore or ulcer (J. Braithwaite) .... 208 
Angioma of the ovaries, atrophy with collapse (cirrhosis), 

fibroid degeneration and (J. Braithwaite) • . 325 

Anntud €fe7ieralMeeHng,Fehmarj 7th, ISH • 61 

Atrophy with collapse (cirrhosis), fibroid degeneration, and 

angioma of the ovaries (J. Braithwaite) . . S25 

Blackbb (G. F.), ruptured uterus (shown) . . 316 

uterus with placenta prasvia marginalis in ntu (shown) • 194 

Boxall (Bobert), uterine fibroids removed by enucleation 

fifteen days after delivery (shown) . . .64 

Bemarha in discussion on J. H. Galton's specimen of 

uterine fibroid . • . . . 819 

•^— in discussion on W. Duncan's specimen of tubal ges- 
tation • . . .69 

Bbaithwaite (James), a case of adenoma of the portio vagi* 

nalis uteri, forming a depressed sore or ulcer • . 208 

on atrophy with collapse (cirrhosis), fibroid degeneration, 

and angioma of the ovaries .... 325 

Bright's disease, six more casesof pregnancy and labour with 

(G. £• Herman) . . . • .9 



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392 INDEX. 

PAGB 

Cancer of the body of the nteros, Taginal hysterectomy for (A. 

H. N. Lewera) . .374 

Oandlish, Henry, M.D., of Ayr, obituary notice of . .90 

Carcinoma, primary, of the body of the ntems in which 

yaginal hysterectomy was performed, &c. (A. H. N. Lewers) 374 

of the Fallopian tube (0. J. Oullingworth) . 307 

Oast, note on the importance of a decidual, as evidence of 

extra-uterine gestation (W. S. A. Griffith) . . 335 

Oelosoma, see Monsters. 
Cervical canal, see Uterus, 
Oervix, see Uterus (cervix of). 
Ohampnbts (Francis H.)> Bemarhs in discussion on B. Boxall's 

specimen of uterine fibroids removed by enucleation fifteen 

days after 'delivery . . . . .65 
in discussion on W. Duncan's specimen of a fostus 

and placenta removed by laparotomy, from a case of extra- 
uterine gestation ...... 147 

^— Beport as Ghairmaii of the Board for the Examination of 

Midwives '. . . . .73 

Ohepmbll (Charles), uterus from a septic case . 3 

Clay, Charles, M.D., of Poulton-le-Fylde, obituary notice of . 100 
Clitoris, hypertrophied nymphsB and (W. Duncan) . 3, 149 

Collapse (cirrhosis) fibroid degeneration, and angioma of the 

ovanes, atrophy with (J. Braithwaite) . . ^ 325 

Cbawfobd (James), fibroma of the ovary (shown) . . 190 

CuiiLiNOWOBTH (C. J.), large gangrenous interstitial myoma 

of the uterus (shown) .... 268 

Bemarhs in reply ..... 270 

primary carcinoma of the Fallopian tube (shown) . 307 

three cases of pelvic inflammation attended with abscess 

of the ovary, with clinical remarks . . . 277 

— Bemarhs in reply ..... 299 
^ in discussion on A. E. Giles's paper on temperature 

inrelationto the duration of labour . . . 249 
in discussion on G. E. Herman's paper on pregnancy 

and labour with Bright's disease . . • ^9 

— ^ '■ — in discussion oh G. E. Hierman's paper on the change 

in size of the cervical canal during menstiniation • 258 

— - -^ — in discussion on W. Duncan's specimen of fibroid 

polypus of cervix ..... 115 
— — -^— r- in discussion on W. Duncan's specimen of tubal ges- 



tation 



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IKDBX. ^9^ 

PAGE 
OuiiLiNOWOBTH (C- J.)> Bemarhs in discassion on W. B. 

Dakin's specimen of sarcoma of ovary . . . 314 

OuTLEB (Leonard), kidneys from a case of eclampsia 

(shown) .. . . .176 

Cyclops, case of ( W. J. McO. Ettles) . .149 

Cyst, dermoid, of right ovary ; twisted pedicle (W. Dnncan) . 267 
Cysts, on cases of associated parovarian and vaginal, formed 

from a distended Gartner's dnct (Amand Bonth) . 152 



Dakin (W. B.), concealed accidental haamorrhage; fcBtus, 

placenta, and membranes delivered entire (shown) . 315 

sarcoma of ovary (shown) .... 313 

Bemarhs in discassion on J* Braithwaite's paper on ade- 
noma of the portio vaginalis uteri . . . 210 

— in discussion on W. Duncan's specimen of gan- 
grenous uterine fibroid removed by abdominal hysterec- 
tomy . .184 
in discussion on W. Duncan's specimen of tubal 



gestation . . . . .70 

Beport as Honorary Librarian . .73 

Deformities, see Malformationa, 

Deformity, curious congenital (C^ H. Boberts) . 341 

Degeneration, fibroid, and angioma of the ovaries, atrophy 

with collapse (cirrhosis) (J. Braithwaite) . . 328 

uterine fibroid undergoing colloid (T. G. Stevens) . 225 

DoBAN (Alban), Bemarks in discussion on A. H. N. Lewers's 

paper on primary carcinoma of the body of the uterus . 887 
-* in discussion on A. Bouth's paper on cases of asso- 
ciated parovarian and vaginal cysts formed by a distended 
Gartner's duct ..... 170 

in discussion on C. J. Cullingworth's specimen of 

primary carcinoma of the Fallopian tube . . 311 

- in discussion on T. W. Eden's specimen of unrup- 



tured tubal gestation . . . 6, 7 

- in discussion on W. Duncan's specimen of a foBtus 



and placenta removed by laparotomy from a case of extra- 
uterine gestation . . . 148 
> in discussion on W. Duncan's specimen of hypertro- 



phied nymphs and clitoris . . . . 150 

— in discussion on W. Duncan's specimen of tubal ges- 
tation % -. . ; .70 



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894 INDEX. 

PAOI 
DoBAN (Alban), Bemarh$ in diacassion on W. Heape's paper 

on menstrnation of SemnopUhectis etUelhu . . 228 

Downes, Dennis Sidney, L.K.Q.C.P.L, of Kentish Town, N.W. 

obituary notice of . . . . .91 

Duncan (William), cystic sarcoma of omentum simulating ova- 
rian tumour; removal; recovery (shown) . 264 

dermoid cyst of right ovary; twisted pedicle (shown) • 267 

— — fibroid polypus of cervix (shown) . . 114 

-^— Bemarhs in reply ..... 116 

— foBtus and placenta removed by laparotomy from a 

case of extra-uterine gestation (shown) • 146 

Bemarh$ in reply ..... 148 

— — gangrenous uterine fibroid removed by abdominal hyste- 
rectomy (shown) • . . . .181 
•^— Bemarha in reply ..... 184 

Hypertrophied nymphas and clitoris (shown) . 3, 149 

ovarian tumour complicating pregnancy ; cyst ruptured 

during examination; immediate laparotomy ; recovery 
(shown) . . . . . .312 

ruptured tubal gestation (shown) . . 114 

•^— tubal gestation of nine weeks* duration, successfully re- 
moved three hours after rupture (shown) . . 66 

— EemarAw in reply . .70 
in discussion on C. J. Oullingworth's paper on pelvic 

inflammation attended with abscess of the ovary . 298 

— — in discussion on G. E. Herman's paper on pregnancy 
and labour with Bright's disease . .50 

— — in discussion on L. Bemf ry's paper on ligature and 
division of the upper part of both broad lig^aments . 206 

in discussion on T. W. Eden's specimen of un- 
ruptured tubal gestation. . . .6 



Eclampsia, kidneys from a case of (L. OuUer) • . 176 

Edbn (T. W.), unruptured tubal gestation (shown) . • 5 

meetian of new FeUom . 1, 113, 173, 189, 213, 261, 301, 841 

Enucleation, uterine fibroids removed by, fifteen days after de- 
livery (B. Boxall) . .64 
Ettlbs (W. J. McC), case of cyclops (shown) . . 149 
— — .BemorAM in discussion on W. Duncan's specimen of a 
foBtus and placenta removed by laparotomy from a case of 
extra-uterine gestation • • • 148 



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INDEX. 305 

pAas 
PaUopian tabe and ovary, dilated (T. G. Hayes) . . 185 

ovarian tumour with greatly enlarged (P. Horrooks) . 185 

primary carcinoma of (0. J. Gallingworth) . • 307 

Pabbab (Joseph), a new and speedy method of dilating a rigid 

OS in parturition ..... 321 

Bemarhs in reply • . . . • 324 

Fellows, see LUts^ Elections. 

Fbnton (Hugh), Bemarh$ in discussion on W. Duncan's speci- 
men of a foBtus and placenta removed by laparotomy, from 
a case of extra-uterine gestation . • 148 

Fibroids, see Tumawrs (fibroid). 

— (uterine). 

Fibroma of ovary (M. Handfield- Jones) . . . 343 

of the ovary (J. Crawford) .... 190 

(P)oftheovai7(P. Horrocks) . . .192 

spontaneously enucleated (Amand Bouth) . • 2 

Fibromata, on intermittent contractions of uterine, and in 

pregnancy in relation to diagnosis (J. B. Hicks) . 188 

Fostus and placenta removed by laparotomy from a case of 

extra -uterine gestation (W. Duncan) . . 146 

at seven months, illustrating celosoma with retroflexioui 

meningocele, and talipes varus (Leith Napier) . . 116 

case of exomphalic (A. E. Giles) . . . 174 

placenta, and membranes delivered entire, concealed 

accidental hsBmorrhage (W. B. Dakin) . . . 315 
see Monsters, 



<}alabin (A. L.), Bemarhs in discussion on 0. J. CuUingworth's 
paper on pelvic inflammation attended with abscess of the 
ovary . . . . , .297 

CIalton (J. H.), uterine fibroid (shown) . . .318 

Bemarhs in reply ..... 320 

Partner's duct, on cases of associated parovarian and vaginal 

cysts, formed from a distended (Amand Bouth) . 152 

Xakstation, see Pregnancy, 

(extra-uterine). 

OiLBB (Arthur E.), a case of exomphalic fostus (shown) . 174 

temperature immediately after delivery in relation to the 

duration and other characteristics of labour • . 238 
Bem,a/rhs in discussion on G. E. Herman's paper on preg- 
nancy and labour with Bright's disease • • 60 



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396 INDEX. 

PAGE 

Giles (Arthur E.)i Bemarks in discussion on G. E. Herman's 
paper on the change in size of the cervical canal during men- 
struation ......' 258 

'^— in discussion on L. Remfry's paper on foetal retro- 
flexion . . . « . .236 

Gluteus maximus, remarks on foBtal retroflexion : report of a spe- 
cimen showing origin of, from occipital bone (L.Bemfrj). 227 

Gow (William John), a note on vaginal secretion . . 52 

— Bemarha in reply . . .69 

— - on the relation of heart disease to menstruation . 126 

Gbivfith (Walter S. A.), note on the importance of a decidual 

cast as evidence of extra-uterine gestation . . 335 

— — .Beworfc* in discussion on A. H. N. Lewers's paper on 

primary carcinoma of the body of the uterus . . 387 

in discussion on 0. H. Boberts' specimen of cunous 

congenital deformity .... 343 

in discussion on 0. J. OuUingworth's paper on 

pelvic inflammation attended with abscess of the ovary . 298 

in discussion on R. P. Harris's paper on a plea for the 

practice of symphysiotomy, based upon its record for the 
past eight yeara . . . . 123 

in discussion on W. Heape's paper on menstruation 

of SemnopUhecuB erUellus .... 223 
• in discussion on W. J. Gow's paper on the relation 



of heart disease to menstiniation . . . 144 

Gbooono (A. W.), see 0, E. Herman. 

Haamorrhage, concealed accidental ; foetus, placenta, and mem- 
branes delivered entire (W. B. Dakin) . . 315 
Hall, Frederick, M.D.St. And., of Leeds, obituary notice of 99 
Handfield- Jones (M.), fibroma of ovary . . .343 
Hardey, E!ey, of Wardrobe Place, E.G., obituary notice of .91 
Habbis (Robert P., of Philadelphia), a plea for the practice of 
symphysiotomy, based upon its record for the past eight 
years ...... 117 

Hayes (T. 0.), dilated Fallopian tube and ovary (shown) . 185 

— Bemarha in discussion on 0. J. Oullingworth's specimen 

of a large gangrenous interstitial myoma of the uterus . 269 

— — in discussion on 0. J. Oullingworth's paper on 
pelvic inflammation attended with abscess of the ovary . 296 

Heape (Walter), the menstruation of Semnopithecus enteUus . 213 
•— — Bemarhs in reply .. . . 224 



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INDEX. 807 

PAOB 

Heart disease, on the relation of, to menstimation ( W. J. Gk>w) 126 

Heart, malformed (B. J. Probyn- Williams) . . 3 

Hebman (G. Ernest), Annual Addreai as President . 75 

for A, W. Qrogono, acephalous acardiac foatus (shown) . 65 

— — on the change in size of the cervical canal during men- 
struation ...... 250 

— Bemarhs in reply ..... 259 
six more cases of pregnancy and labour with Bright's 

disease « . « . . .9 

— Bemarhs in reply . . . r 61 

— '■ in discussion on A. E. Giles's paper on temperature 

in relation to the duration of labour . . • 249 

r — in discussion on A. H. N. Lewers'B paper on primary 

carcinoma of the body of the uterus . . 388 
in discussion on A. Bouth's paper on cases of asso- 
ciated parovarian and vaginal cysts, formed from a dis- 
tended Gartner's duct .... 170 
^— — in discussion on 0. H. Roberts's specimen of curious 

congenital deformity .... 842 

in discussion on 0. J. Oullingworth's paper on pelvic 



inflammation attended with abscess of the ovary 

' in discussion on G. F. Blacker's specimen of ruptured 



uterus ...... 318 

in discussion on G. F. Blacker's specimen of a uterus 

ydth placenta prsBvia marginalis in situ . . 195 
in discussion on J. Braithwaite's paper on adenoma 

of the portio vaginalis uteri .... 211 
in discussion on J. Braithwaite's paper on atrophy 

idth collapse ..... 333 

• in discussion on J. B. Sutton's specimen of an early 



tubal ovum . . . . . 199 

. in discussion on J. Farrar's paper on a new and 

speedy method of dilating a rigid os in parturition . 324 
in discussion on L. Cutler's specimen of kidneys from 

a case of eclampsia ..... 180 
• in discussion on L. Bemfry's paper on foBtal retro* 



flexion ••.... 237 
- •: in discussion on L. Remfry's paper on ligature and 

division of the upper part of both broad ligameilts . 206 

" 1 in discussion on R. P. Harris's paper on a pleU for 

the practice of symphysiotomy, based upon its record for 

the past eight years .... 124 



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898 INDEX. 

PAas 
Herman (G. Ernest), Bemarhs in discassion on T. W. Eden's 

specimen of unniptnred tubal gestation . . 8 
in discussion on W. Duncan's specimen of a fostus 

and placenta removed by laparotomy, from a case of extra- 
uterine gestation ..... 148 
— in discussion on W. Duncan's specimen of fibroid 

polypus of cervix . . . . , 115 
in discussion on W. Heape's paper on menstruation 

of 8emnopUhecu8 entellua .... 224 
— in discussion on W. J. Gow's paper on the relation 

of heart disease to menstruation . . . 144 
in discussion on W. J. Glow's paper on vaginal 

secretion . . . . . .59 

Hermaphroditism, two cases of pseudo- (J. H. Targett) . 272 

Hewitt, William Morse Graily, M.D., of Berkeley Square, W„ 

obituary notice of . . . . .92 

Hicks (J. Braxton), on intermittent contractions of uterine 

fibromata, and in pregnancy, in relation to diagnosis . 188 
Bemarlcs in discussion on W. Duncan's specimen of tubal 

gestation . . . . .70 
in discussion on R. Boxall's specimen of uterine 

fibroids removed by enucleation, fifteen days after delivery 65 
Hope, William, M.D., of Ourzon Street, W., obituary notice of 90 
HoBBOCKS (Peter), fibroma (P) of the ovary (shown) . . 192 

— Bemarha in reply ..... 192 

large fibroid tumour of the utei-us (shown) • . 193 

large sarcoma of the ovary (shown) . . . 192 

ovarian tumour with greatly enlarged Fallopian tube 

(shown) ...... 185 

see T, G, Stevens. 

Bemarhs in discussion on A. H. N. Lewers's paper on 

primary carcinoma of the body of the uterus • • 385 
— in discussion on G. E, Herman's paper on pregnancy 

and labour with Bright's disease . . .51 
in discussion on J. B. Sutton's specimen of an early 

tubal ovum ..... 199 

— — in discussion on J. Farrar's paper on a new and 
speedy method of dilating a rigid os in parturition . 323 

in discussion on J. H. Galton's specimen of uterine 

fibroid . . . . . .319 

— in discussion on L. Bemfry's paper on ligature and 

division of the upper part of both broad ligaments • 205 



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INDEX. 399 

PAOB 

HoBBOCKS (Peter), Bemarh$ in disciiBsion on B. P. Harris's 
paper on a plea for the practice of symphysiotomy, based 
upon its record for the past eigHt years . . 122 

in discussion on W. Duncan's specimen of fibroid 

polypus of cervix . • • 115 

in discussion on W. Duncan's specimen of gangre- 



nous uterine fibroid removed by abdominal hysterectomy 184 
in discussion on W. Duncan's specimen of tubal 



gestation . . . . .70 

• in discussion on W. J. Gow's paper on the relation 



of heart disease to menstruation . 143 

• in discussion on W. J. Crow's paper on vaginal se- 



cretion . . . . . .59 

Hutton, Robert James, L.B.G.P.Ed., of Stapleton Hall Boad, 

N., obituary notice of . . . .89 

Hydatids in the pelvis, see Pelvis. 

Hydrocephalus with spina bifida (B. J. Probyn- Williams) . 4 
Hysterectomy, gangrenous uterine fibroid removed by abdo- 
minal (W. Duncan) ..... 181 

, vaginal, in a case of primary carcinoma of the body of 

the uterus (A. H. N. Lewers) .... 374 

Inflammation, three cases of pelvic, attended with abscess of 

the ovary, with clinical remarks (0. J. Gullingworth) . 277 

Kidneys from a case of eclampsia (L. Cutler) . . 176 

Labour, see ParturUion, 

temperature immediately after delivery in relation to 

the duration and other characteristics of (A. E. Giles) . 238 

with Bright's disease, six more cases of pregnancy and 

(G. E. Herman) . . . .9 

Laparotomy, fcBtus and placenta removed by (W. Duncan) • 146 

immediate in a case of ovarian tumour ( W. Duncan) . 312 

Lbwbbs (Arthur H. N.), a case of primary carcinoma of 
the body of the uterus in which vaginal hysterec« 
tomy was performed, and more than two years have 
elapsed without recurrence; with a table of five other 
cases of vaginal hysterectomy for cancer of the body of 
the uterus ...... 374 

BemorAM in reply ..... 889 

fibro-cystic tumour of the uterus removed by abdominal 

section (shown) • . • . • 270 



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400 INDEX. 

PAOB 
Lbw£B8 (Arthar H. N.), Bemarks in discussion on G. J. 
Onllingworth's paper on pelvic inflammation attended with 
abscess of the ovary . . • . . 299 

in discussion on B. P. Harris's paper on a plea for 

the practice of symphysiotomy, based upon its record for 
the past eight years . ... . . 121 

in discussion on W. J. Gow's paper on vaginal 

secretion . . . . . .59 

lagaments, ligature and division of the upper part of both 
broad, and the result as compai*ed with that following 
removal of the uterine appendages (L. Remfry) . . 202 

Ligature and division of the upper part of both broad liga- 
ments, and the result as compared with that following 
removal of the uterine appendages (L. Bemfry) . . 202 

List of Officers elected for, 1S9^ . . . .110 

of ditto for 1S9S . . . . . T 

of past Presidents . . . . • vii 

of Referees of Papers for 189S . . . viii 

of Standing Committees . . . . ix 

of Honorary Local Secretaries . . . x 

• of Honorary Fellows . . . . xi 

of Corresponding Fellows . . .^ . xii 

of Ordinary Fellows .... xiii 

of Deceased Fellows [with obituary notices, which see] 89-110 

Malcolm (J. D.), uterine fibroids (shown) . . . 200 

Remarks in reply ..... 201 

in discussion on A. H. N. Lewers's paper on primary 

carcinoma of the body of the uterus . . . 387 
in discussion on J. Braithwaite's paper on atrophy 

with collapse *. *. . . . 834 

Malformation, heart (B. J. Probyn-Williams) . . 3 

see Monster, 

Malformations, foetus at seven months illustrating celosoma 

with retroflexion, meningocele, and talipes varus (Leith 

Napier) . . . . .116 

Meningocele, see Malformations, 

'M.euBtrviB.tion ot Sem/nopithectis entellns (W. Heape). . 213 

^ — On the change in size of the 'cervical canal during (G. E. 

' Herman) '. •. •. *. . . 250 

— — on the relation of heart disease to (W. J. Qow) . . 126 

Monster, acephalous acardiao fostus (G. E; Herman) ; 65 



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.INDEX, 401 

PAGE 

Monsters, foBtus at seven months illustrating celosoma with 

retroflexion, meningocele, and talipes yarns (Lelth Napier) 116 

Myoma of the utems, large gangrenous interstitial (0. J. 

Oullingworth) .. ... . .268 

Napieb (Leith), foetus at seven months illustrating celosoma 

with retroflexion, meningocele, and talipes varus (shown) 116 

' Bemarha in discussion on J. Braithwaite's paper on 

atrophy with collapse • . • • • 384 

— •— in discussion on J, Farrar's paper on a new and 

»peedy method of dilating a rigid os in pai*turition • 323 

• in discussion on R. P. Harris's paper on a plea for 



the practice of symphysiotomy, based upon its record for 
the past eight years .... 124 

• in discussion on W. S. A. Griffith's note on the impor- 



tance of a decidual oast as evidence of extra-uterine gesta- 
tion ...... 340 

Nymphsd and clitoris, hypertrophied (W. Duncan) . 3, 149 



OhUuary notices of deceased Fellows — 

Gandlish, Henry, M.D., Ayr . .90 

Clay, Charles, M.D., Poulton-le-Fylde . . .100 

Pownes, Dennis Sidney, L.K.Q.C.P.I., Kentish Town, 
. KW.. ...... 91 

Hall, Fredei-ick, M.D.St. And., Leeds . . .99 

Hardey, Key, Wardrobe Place, E.G. . . .91 

Hewitt, William Morse Graily, M.D., Berkeley Square, W. 92 
Hope, William, M.D., Ourzon Street, W. . .90 

fiutton, Robert James, L.R.G.REd., Stapleton Hall Road, 

^ • N. .. .. ... . .89 

Bhibbs, FeatherstQne, M.R.G.P.£d., Elgin Avenue, W. .89 
Tilt, Edwai'd John,^.D., Seymour Street, W. « . 107 

Oliybb (James), BemarJcsm discussion on A. Routh's paper 
on cases of ^ associated parovarian and vaginal cysts, formed 

■■ ^ • 4>y a distended Garkier's duct . .. . 171 

Omentum^, cystic ««rooma <of, simulating ovarian tumour ; re* ^ 
moval ; recovery ( W. Duncan) .. . . , 264 

Os uteri, see 4*<0rt» (rigid os). 

Ovarian tumour complicating pregnancy ; cyst ruptured during 
examinatioii ; cMi^medigiti laparotomy; recovery (W. 
— Duncan) •. •• ■. « .' • .' ., -. , 812 



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402 INDEX. 

PAOK 

Orarian tamour with greatly enlarged Fallopian tube (F. 

Horrocks) ...... 185 

Oraries, atrophy with collapse (cirrhosis), fibroid degenera- 
tion, and angioma of (J. Braithwaite) . . • 825 

two cirrhotic and cystic, with microscopical section of 

same (L. Remfry) ..... 184 
Ovary, dermoid cyst of right ; twisted pedicle (W. Duncan) . 267 

dilated Fallopian tnbe and (T. 0. Hayes) . . 185 

fibroma of (J. Crawford) . . . .190 

(M. Handfield- Jones) . . . .843 

(P) of (F. Horrocks) . . . .192 

large sarcoma (?) of (F. Horrocks) . . . 192 

sarcoma of (W. R. Dakin) .... 813 

three cases of pelvic inflammation attended vrith abscess 

ofthe(0. J.Oullingworth) . . , .277 

Ovum, on an early tubal (J. Bland Sutton) . . • 195 

Farturition, a new and speedy method of dilating a rigid os in 

(J.Farrar) . . . . .821 
with Bright's disease, six more cases of pregnancy and 

(G.E.Herman) . . . . .9 

Fedicle, twisted, in dermoid cyst of right ovary ( W. Duncan) . 267 
Felvis, hydatids in the bony (J. H. Targett) • • 844 

Fhibbs, Featherstone, M.R.O.F.Bd., of Elgin Avenue, W., 

obituary notice of . . . . .89 

Fhillips (John), Bemarhs in discussion on W. J. GbVs paper 

on the relation of heart disease to menstruation • 142 

Flacenta and fcBtus removed by laparotomy from a case of 

extra-uterine gestation (W. Duncan) . . • 146 
foBtus, and membranes delivered entire ; concealed acci- 
dental hsBmorrhage (W. B. Dakin) . . . 815 
— -^ prasvia marginalia, uterus with, in aiiu (G. F. Blacker) • 194 
Folj^us (fibroid) of cervix (W. Duncan) . . • 114 
Fortio vaginalis uteri, adenoma of the, forming a depressed 

sore or ulcer (J. Braithwaite). . . . 208 

FOTTEB (J. B.)i Beport as Treasurer . . 71, 72 

Pregnancy and labour with Bright's diaeas^, six more oases 

of (G. E. Herman) . . . . .9 
extra-uterine, note on the importance of a decidual cast as 

evidenceof(W.S. A. Griffith) . . .835 
foBtus and placenta removed by laparotomy from a case of 

e^tra-uterine (W. Duncan) • .. • . 146 



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INDEX. 403 

« 

PAOS 

Pregnancy in a rudimentary horn (L. Bemfry) . . 263 

ruptured tubal (W. A. Stott) . . .843 

ruptured tubal (W. Duncan) . • • 114 

tubal, of nine weeks' duration successfully removed three 

hours after rupture (W. Duncan) • • .66 

unruptured tubal (T. W. Eden) . . ,5 

F&OBYN-WiLLiAMS (B. J.)f abscess in abdominal wall 

(shown) . . . . ,62 

— - hydrocephalus with spina bifida (shown) . . 4 

— malformed heart (shown) • . • .3 



Bbmfby (L.), gestation in a rudimentary horn . • 263 

•*— incomplete tubal abortion .... 261 
»— ligature and division of the upper part of both broad 
ligaments, and the result as compared with that following 
removal of the uterine appendages . . • 202 

— Remarks in reply ..... 207 
— on foBtal retroflexion ; report of a specimen showing 

origin of gluteus maximus from occipital bone . . 227 

Bemmlf in reply ..... 237 

-^— two cirrhotic and cystic ovaries, with microscopical 

section of same (shown) .... 184 

-^- Eemarha in discussion on W. S. A. Griffith's note on the 

importance of a decidual cast as evidence of extra-uterine 

gestation ...... 340 

B^ort (audited) of the Treasurer for 1893 . . 71, 72 

-^-^of (he Hon. Librarian for 189S . . .73 

— of the Chairman of the Board for the Examination of Mid* 
wivee . • • . • . .73 

— »- of CommiUee on Dr, Amand Bouth*9 epecimen of fibroma 
epontaneouely enucleated, shouni November let, 1893 
(' Transactions,' xxxv, p. 409) . . . .2 

— — — on Dr, Duncan's speeimsn of hypertrophied vulva, 

shoum January 3rd, 1894 (p. 3) . . . 150 

on Mr, Qrogono*s specimen offcetus aeephalus aeardiO' 



eus, shown February 7th, 1894 (p. 65) . . .185 

— — on a tumour removed from the abdomen, July 22nd, 1894, 

by Dr. William Duncan .... 265 

^'^'^ of Committee on Dr, Eden's specimen of tubal mole ex* 

hibOed on January Ml, 1894 (p. 5) • . .301 

— «— » on Dr, LeUh Napier's specimen cf deformed fodus • 302 



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v404 INDEX. 

PAOB 
Betroflezion, fostal, report of a specimen showing origin of 

gluteus maximus from occipital bone (L. Remfrj) . 227 

^-^— of foQtus . at seven months, illustrating celosoma with 

(Leith Napier) ..... 116 

BoBEBTS (G. H.), curious congenital deformity (shown) . 341 

BemarJea in replj ... . « 342 

BouTH (Amand), fibroma spontaneouslj enucleated (shown) . 2 
on cases . of associated parovarian and vaginal cjsts, 

formed from a distended (Hrtner's duct . . 152 

Bemarka in reply ..... 171 

in discussion on A. E. Giles's specimen of a case of 

exomphalic foetus ..... 176 
^ in discussion on A. H. N. Lewers's paper on primary 

carcinoma of the body of the uterus . . . 386 
in discussion on G. E. Herman's paper on pregnancy . 

and labour with Bright's disease . .50 
• in discussion on J. Braithwaite's paper on adenoma 

of the portio vaginalis uteri .... 210 
in discussion on T. D. Malcolm's specimen of uterine 

fibroids . . . . . .200 

in discussion on J. Farrai*'s paper on a new and 

speedy method of dilating a rigid os in parturition . 323 
in discussion on L. Bemfry's paper on foetal retro* 

flexion ...... 237 

in discussion on L. Bemfry's paper on ligature 

and division of the upper part of both broad liga- 
ments ...... 206 

• in discussion on W. Heape's paper on menstruation 



of Semnopithetms erUellua 
BouTH (G. H. F.) Remarks in discussion on G. E. Hermanns 
paper on the change in size of the cervical canal during 
ijienstruation ..... 258 



^Sarcoma, cystic, of omentum, simulating ovarian tumour ; re* 

moval ; recovery (W. Duncan) . . . 264 

— <P) large, of the ovary (P. Horrocks) . . .192 

of ovary (W.B.Dakin) . . . .313 

SoHACHT (F. F.), Bemarka in discussion on T. W. Eden's speci- 
men of unruptured tubal gestation , . .7 
iSecretion, a note on vaginal (W. J. Gk)w) . . .52 
•Semnopithecus entellus, menstruation of (W. Heape) . 213 



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INDEX. 405 

PAOB 

Smith (Heywood), Bemarhs in discussion on 0. J. Oulling- 
worth's specimen of a large gangrenous interstitial myoma 
oftlle^terus . . . . -270 

in discussion on J. H. Galton's specimen of uterine 

fibroid . . . . .319 

Spencbs (Herbert), Bemarhs in discussion on A. Boutli's 
paper on cases of associated parovarian and vaginal cysts, 
formed by a distended Gartner's duct . . .170 

Spina bifida, hydrocephalus with (R. J. Probyn- Williams) . 4 
Stevens (T. 6.), for Peter Horroeks, uterine fibroid undergoing 

colloid degeneration .... 225 
Stott (W. Atkinson), ruptured tubal pregnancy (shown) . 343 
Sutton (J. Bland), on an early tubal ovum (shown) . .195 
Remarks in discussion on T. W. Eden's specimen of unrup- 
tured tubal gestation . . .7 
Symphysiotomy, a plea for the practice of, based upon its 

record for the past eight years (R. P. Harris) . . 117 



Talipes varus, see MalformationB, 

Tasobtt (J. H.), hydatids in the bony pelvis * . 344 

two cases of pseudo- hermaphroditism . . . 272 

Eemarlc$ in discussion on J. Braithwaite's paper on 

atrophy with collapse .... 334 

Temperature immediately after delivery in relation to the dura- 
tion and other characteristics of labour (A. E. Giles) . 238 

Tilt, Edward John, M.D., of Seymour Street, W., obituary 

notice of * . . . . . . 107 

(Mrs.), vote of thanks for donation of books and resolution 

of condolence with ..... 190 

Tubal gestation, see PregtMncy. 

Tumour, adenoma of the portio vaginalis uteri forming a 

depressed sore or ulcer (J. Braithwaite) . 208 

^— carcinoma, primary, of the body of the uterus (A. H. N. 

Lewers) ...... 374 

cystic sarcoma of omentum simulating ovarian ; removal ; 

recovery (W. Duncan) .... 264 

^— fibroid, gangrenous, uterine, removed by abdominal hys- 
terectomy (W. Duncan) .... 181 

fibroid polypus of cervix ( W. Duncan) . . 114 

fibroid, uterine (J. H. Galton) . .318 

(J.D.Malcolm) . . . .200 

VOL. xxzvi. 28 



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406 INDEX. 

PAOS 

Tumour, uterine, fibroids removed bj enucleation fifteen dajs 

after delivery (R. Boxall) . .64 

fibroma of ovary (J. Crawford) . . . 190 

(M. Handfield- Jones) .... 343 

(P) of the ovary (P. Horrocks) . . .192 

fibromata, on intermittent contractions of uterine, and 

in pregnancy, in relation to diagnosis (J. B. Hicks) . 188 

large fibroid, of the uterus (P. Horrocks) . . 193 

of the uterus, fibro-cystic, removed by abdominal section 

(A. H. N. Lewers) . . . . .270 
ovarian, complicating pregnancy, cyst ruptured during 

examination; immediate laparotomy; recovery (W. 

Duncan) . . . . .312 

— primary carcinoma of the Fallopian tube (0. J. Oulling- 
worth) . . . . .307 

sarcoma (P), large, of the ovary (P. Horrocks) . . 192 

of ovary (W. R. Dakin) . . .313 

see Cysts. 

Uterus, a new and speedy method of dilating a rigid os in 

parturition (J. Farrar) .... 321 

appendages of, ligature and division of the upper part of 

both broad ligaments, and the result as compared with 
that following removal of (L. Remfry) . . . 202 

cervix, fibroid polypus of, see Tumours. 

— fibroid tumour of, see Tumours. 

— fibromata of, see Tumours. 

— from a septic case (0. Ohepmell) . .8 
^— large interstitial gangrenous myoma of (0. J. Gulling- 

worth) . . . .268 

— — on the change in size of the cervical canal during men- 
struation (G. E. Herman) .... 250 
— - portio vaginalis uteri, adenoma of, see Tumours. 

— primary carcinoma of the body of (A. H. N. Lewers) • 374 

ruptured (G. F. Blacker) . . .316 

«— - see Tumours (fibro-cystic). 

— with placenta previa marginalis tti situ (G. F. Blacker) . 194 



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Presented by 
Acton (William). Prostitution, considered in its 
moral, social, and sanitary aspects, in London and 
other large cities and ^rrison towns, with pro- 
posals for the control and prevention of its attend- 
ant evils; second edition. 8vo. Lond. 1870 Mrs. Tilt. 

Ahlfeld (F.) Lehrbuch der Gkburtshilfe zur wissen- 
schaftlichen und praktischen Ausbildung fiir 
Aerzte und Studierende. 

plates, 8vo. Leipzig, 1894 Purchased. 

Ash WELL (Samuel). Practical Treatise on the Diseases 

peculiar to Women. 8vo. Lond. 1845 Mrs. Tilt. 

Baldt (J. M.^. System of Gynecology, Medical and 

Surgical, plaiee and woodcute, la. 8vo. Lond. 1894 Purchased. 

Ballaitttki (J. W.). See Journals, Teratologia. 

BiDFOBD (Qunning S.). Clinical Lectures on the Dis- 
eases of Women and Children. 

8vo. New York, 1866 Mrs. Tilt. 

BoiTBOOXTaKON (H.). Becherches sur Tfitat du Coeur k 
la fin de la Qrossesse et dans les suites de 
couches. Th&se. 4to. Paris, 1884 Purchased. 

BoxALL (Robert). The Use of Antiseptics in Mid- 
wifery, their value and practical application. 

chaHs, 8vo. Lond. 1894 Author. 

Bbaun t. Fibnwjlld (Richard) . Der Eaiserschimtt bei 

engem Becken. 8vo. Wien, 1894 Purchased. 

tl)erUteruBruptur. 8vo. Wien, 1894 Ditto. 



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Preaetded hy 
Brown (Isaac Baker). On some Diseases of Women 
admitting of Surgical Treatment. 

plcUes and woodcute, 8vo. Lond. 1854 Mrs. Tilt. 

BuHM (P.). Die Frauenmilch, deren Veranderlichkeit 
und Einfluss auf die Sauglingsernahrung. ('Volk- 
mann's Sammlung/ neue Folge, No, 105.) 

8yo. Leipzig, 1894 Purchased. 

Catalogue of the Library of the Eoyal Medical and 
Ghirurgical Society. Supplement VIL Addi- 
tions to the Library, 1892-3. 8vo. Lond. 1893 Society. 

of books added to the Eadcliffe Library during Sir. H. W. 

1893. 4to. Oxford, 1894 Acland, 

Oazbatjx (P.). Des Kystes de TOvaire. Th^se. K.C.B. 

8vo. Paris, 1844 Mrs. Tilt. 

Gblsus (Aurelius Cornelius). See EncyclopSdie des 
Sciencee Mddicdlee. 

Chazan (Samuel) . tJber Placentarretention nach recht- 
zeitiger Geburt. (* Volkmann's Sammlung * neue 
Folge, No. 93.) 8vo. Leipzig, 1894 Purchased. 

Cholmogoroff (S.). Die vaginale Totalexstirpation 
des Uterus (* Volkmann's Satnmlang,* neue Folge, 
No. 108). 8vo. Leipzig. 1894 Purchased. 

Chrobak (B.). See Beports, Festschrift. 

CoRRADi (Alfonso). Deir Ostetricia in Italia dalla 
met^ dello scorso Secolo fino al presente ; Com- 
mentario in risposta al programma di Concorso Soc. Italiana 
della Society Medico-Chirurgica di Bologna per di Ostetricia e 
TAnno 1871. Vol. i. 4to. Bologna, 1874 Ginecologia. 

Crbd^ (C. S. F.) and G. Leopold. A short guide to 
the Examination of Lying-in Women, translated 
by William H. Wilson. 

woodcuts, 8vo. Lond. 1894 Purchased. 

Dermiony (Albert). Des Kystes bydatiques du cul-de- 
sac de Douglaschez la femme. These pour le 
Doctorat en Medecine. Faculty de M6decine de 
Paris. 4to. Paris, 1894 Ditto. 

DoHRN (Rudolf). iDTber Leistung von Kunsthilfe in 
der geburtshilflichen Praxis. ('Volkmann's 
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Perforation und Sectio csBsarea. (* Volkmann's 
Sammlung,' neue Folge, No. 99.) 

8vo. Leipzig, 1894 Ditto. 

D&HBSSBN (A.). tTber eine neue Heilmethode der 
Hamleiterscheidenfisteln, nebst Bemerkungen 
uber die Heilung der iibrigen Harnleiterfisteln. 
(* Volkmann's SammluDg/ neue Folge, No. 114.) 

870. Leipzig, 1894 Ditto. 

Encyclop^die des Sciences MMicales ; Celse. 

8vo. Paris, 1887 Mrs. Tilt. 

Biographic M6dicale. 2 vols. 8vo. Paris, 1840-41 Ditto. 

Fababeuf (Pierre). Les bienfaits de la Sjmphjs^o- 

tomie. 8vo. Paris, 1893 Purchased. 

Fbitsch (Heinricb). E[linik der geburtshiilflichen 
Operationen ; fiinf te Auflage. 

woodcuts, 8yo. Halle a. S. 1894 Ditto. 

Fbommel (Richard). See B^orte, Jahresbericht. 

GaIiABIn (Alfred Lewis). A Manual of Midwifery ; 

third edition. woodcuts, 8yo. Loud. 1893 Author. 

Qabdnbb (Augustus K.). The Causes and Curative 
Treatment of Sterility, with a Preliminary State- 
ment of the Physiology of Generation. 

TpUUes and woodcuts, 8vo. New York, 1856 Mrs. Tilt. 

Gabbioubs (Henry J.). A Text-book of the Diseases 

of Women, plates and woodcuts, 8vo. Pbila. 1894 Author. 

Glaistbb (John). Dr. William Smellie and his Con- 
temporaries: a Contribution to the History of 
Midwifery in the Eighteenth Century. 

portrait amd plates. 8vo. Glasgow, 1894 Purchased. 

Gu^BiN (£douard). Contribution k T^tude des Trauma- 
tismes sur les organes g^nitauz des femmes 
enceintes. 8vo. Paris, 1894 Ditto. 

Hbbman (G. Ernest). DiflScult Labour : a Guide to its 
Management for Students and Practitioners. 

woodcuts, sm. 8vo. Lond. 1894 Author. 

Hbbboott (F. J.). See Siehold, Essai d'une histoire de 
rObst6tricie (translated). 

Hebzfbld (Karl August). Klinischer Bericht uber 
tausend Baucbhoblen- Operationen als Beitrag 
zur Lehre von der Indication und Technik der 
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Ditto. 



KoBTTNiTz (A.). tJber Beckenendlagen. (' Volkmann's 
Sammlung/ neue Folge, No. 88.) 

8yo. Leipzig, 1893 

KtJSTNEB (Otto). See Lying-in Institutional Beports. 

La Tbibouillb (De). Des (Ed^mes chez le Nouveau- 
n6 et Tenfant du premier age. Thfese pour le 
Doetorat en MMecine. Faculty de M^decine de 
Paris. 4to. Paris, 1894 

Lbpaob (Q.). See Eihemont'Dessaignes, Precis d'Ob- 
stitrique. 

Leopold (G-.). See Lying-in Institutions, Beports. 

Madden (Thomas More). Clinical GjnsBCologj : being 
a Hand-book of Diseases peculiar to Women. 

woodcuts, 8vo. Lond. 1893 

Malcolm (John D.). The Physiology of Death from 
Traumatic Fever; a Study in Abdominal Sur- 
gery. 8vo. Lond. 1893 

Mabtin (A.). tJber Kraurosis Vulvae. (*Volkmann's 
Sammlung,' neue Folge, No. 102.) 

8vo. Leipzig, 1894 

Mabtin (L.-F. Albert) . Resultats eloignes de T Ablation 
des Annexes Ut^rines par la Laparotomie. These 
pour le Doctomt en Medecine. Faculte de Mede- 
cine de Paris. 4to. Paris, 1893 

Matobieb (Cb.). Lecons de clinique Obst^tricale, 
recueOlies par le Dr. Demelin. 8vo. Paris, 1893 

Mobooulibff (Jacques), fitude Critique sur les Monu- 
ments Antiques repr^sentant des Scenes d' Ac- 
couchement. Th^se pour le Doetorat en Mede- 
cine. Faculte de Medecine de Paris. 

4to. Paris, 1893 

M0LLEBHEIM (Robert). Die Symphyseotomie. (*Volk- 
mann's Sammlung,' neue Folge, No. 91.) 

8vo. Leipzig, 1894 

MuBBT (Maurice). Des positions trans versales du 
sommet au d^troit inferieur du bassin. (Ext. 
de la 'Revue Medicale de la Suisse romaude,' 
1894.) 8vo. Geneve, 1894 Author. 

Obbilabd (A.). De Tlntervention cbirurgicale dans 
la Grossesse extrauterine lorsque Tenfant est 
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Ditto. 

Author. 

Purchased. 

Ditto. 
Ditto. 

Ditto. 
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PiOHABD (F. L.). Des Abus de la cauterisation et de 
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Matrice. 8vo. Paris, 1846 Mrs, Tilt. 

PiNABD (Adolphe). De I'Agrandissement momentani6 

du Bassin. Svo. Paris, 1894 Author. 

Pozzi (S.). Treatise on Gynaecology, Medical and Sur- 
gical ; translated from the French edition under 
the supervision of, and with additions by Brooks 
H.Wells. Vol. n. 

plates and woodctUs, 8vo. New York, 1892 Purchased. 

Bemt (Sebastien). De T influence de la G-rossesse sur 
la marche des Maladies du Gceur. These. 

4to. Nancy, 1880 Ditto. 

Bibemont-Dbssaignbs (A.) et G. Lefbaoe. Precis 

d'Obst^trique. woodcvis, la. 8vo. Paris, 1894 Ditto. 

BicHABD (D'Aulnay) (Gaston). De rUr^thrite chez la 
Femme ses formes et ses yari^t^s. Th^se pour 
le Doctorat en Medecine. Faculte de M6decine 
de Paris. 4to. Paris, 1893 Ditto. 

BocHB (F.). Contribution a I'^Stude de TEmphyseme 
sous-cutane chez les femmes en couches. These 
pour le Dt>ctorat en Medecine. Faculte de Mede- 
cine de Paris. 4to. Paris, 1894 Ditto. 

BoBSOBB (P.). Zur fotalen Entwicklung des mensch- 
lichen Uterus insbesondere seiner Musculatur. 

plates and woodcvis, 8vo. Wien, 1894 Ditto. 

SoHBADEB (Wilhelm). Woher der therapeutische Mis- 
serfolg der Antisepsis beim Puerperal-fieber. 
(* Volkmann's Sammlung,' neue Folge, No. 95.) 

8vo. Leipzig, 1894 Ditto. 

SiEBOLD (Ed. Gasp. Jac. de). Essai d'une histoire de 
VObst^tricie, traduitavec additions et un Appen- 
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8 Tols., woodcuts, 870. Paris, 1891-92 Ditto. 

SoNBEL (Gamille). Contribution k r£tude des Acces 
eclamptiq^ues et plus particuli^rement de leur 
Pathog&ue. Th^se pour le Doctorat en Medecine. 
Faculty de Mddecine de Paris. 4to. Paris, 1893 Ditto. 

Stbatz (C. H.). Gynacologische Anatomie. Die Ge- 
Bchwiilste der Eierstocke. 

plates and woodcuts, 4to. Berlin, 1894 Purchased. 



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412 ADDITIONS TO THE LIBBABY. 

Presented hy 
Sutton (J. Bland). Tumours, Innocent and Malignant ; 
their clinical features and appropriate treatment. 

plcUes and woodcuU, 8vo. Lond. 1893 Author. 
Tabnieb (S.). Be TAsepsie et de TAntisepsie en Ob- 

8t6trique. plates, Svo. Paris, 1894 Author. 

TcH^B^PKHiNB (Alexandre). Stude sur le Bassin 

oblique ovalaire. 8vo. Paris, 1898 Purchased. 

Tilt (Edward John). On Diseases of Women and 
Ovarian Inflammation ; second edition. 

8vo Lond. 1853 Mrs. Tilt. 



The change of Life in Health and Disease; 

fourth edition. 8vo. Lond. 1882 Ditto. 

ViBNNB (Pierre). Contribution k I'Etude des Hornies 

ombilicales congenitales et de leur traitement. 

These pour le Doctorat en M6decine. Faculty de 

Medecine de Paris. plates, 4to. Paris, 1894 Purchased. 

VoiOT (Leonhard). tTber den Einfluss der Pocken- 
krankheit auf Menstruation, Schwangerschaft, 
Qeburt und Fotus. ('Yolkmann's Sammlung,' 
neue Polge, No. 112.) 8vo. Leipzig, 1894 Ditto. 

Volkmann's Sammlung klinische Vortrage, neue Folge: 

88. Koettnitz, t)ber Beckenendlagen. 
91. Mullerheim, Die Sympbyseotomie. 

98. ChoMan, t)ber FlaceDtarretention nach rechtfceit- 

iger Oebart. 

94. Dohm, t)ber Leistang von Kunsthilfe in der 

geburtBhilflicben Praxis. 

95. Sokrader, Woher der therapeatische Misserfolg 

der Antisepsis bei Puerperalfieber. 

99. Bolder, Die Stellung des Landarztes zur Perfora- 

tion and Sectio caesarea. 
100. Wertheim, Ober die Dorchfiibrbarkeit und den 

Werth der mikroskopischen Untersncbung des 

Eiters entziindlicher Adnezentnmoren wabrend 

der Laparotomie. 
102. Martin^ Uber Kraurosis vulvae. 
105. Bumm, Die Frauenmilch, deren Veranderlichkeit 

and Einfluss auf die Sftuglingsernahrung. 
108. Cholmogoroff, Die vaginale Totalezstirpation des 

Uterus. 
112. Voigt, Ober den Einfluss der Pockenkrankbeit auf 

Menstruation, Schwangerschaft, Geburt und 

Fdtns. 
114. Duhrrsten, t)ber eine neue Heilmethode der 

Harnleiterscheidenfisteln, nebst Bemerkungen 

iiber die Heilung der iibrigen Hamleiterfistehi. 

Wells (Brooks H.). See Fozzi, Treatise on Qjnsecology 
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Presented hy 

Wbbthiim (Ernst); "Ober die Durchfiibrbarkeit and 
den Wertb der mikroskopiscben XTntersncbung 
dea Eiters entzundlicber AdnexeDtumoreD wab- 
rend der Laparotomie (' Yolkmann's Sammlun^/ 
neue Folge, No. 100). 8to. Leipzig, 1894 Purchased. 

Wbsbitbb (G-ustay). Cbroniscbe Herzkrankheiten und 
Pueiperiam. Inaug. Diss. 

4to. St. Gallen, 1884 Ditto. 

WiLsoir (William H.). See Credi and Leopold, 



TRANSACTIONS. 

Ambbican Association of Obstbtbicians and Gtnb- 
colooists — 
Transactions, vol. vi, for 1893. 

8yo. Pbila. 1894 Association. 
Ambbican Qynecological Socibtt — 
Transactions, vol. xviii, for 1893. 

8yo. Pbila. 1893 Society. 

Bbuxellbb — CoNOB^B pISbiodiqub Intbbnationaii db 
GTNicoLoaiB bt d*Ost£tbiqub — 
Comptes-rendus, Ire Session, 1892. 

la 8yo. Paris, 1894. Purchased. 
Clinical Socibtt ov London — 

Transactions, toI. xxrii. 8to. Lond. 1894 Society. 

LtON — SoCliTlS DBS SOIBNCBB M^DICALBB — 

Mimoires etOomptes-rendus, tome zxxi, 1891. 

8to. Lyon, 1892 Society. 
Mbdical Socibtt of London — 

Transactions, toI. xvii. Svo. Lond. 1894 Society. 

Mbdical (Botal) and Chibuboical Socibtt — 

Transactions, vol. Ixxri. 8yo. Lond. 1893 Society. 

Nbw Yobk Acadbmt of Mbdicinb — 

Transactions ; second series, toI ix. 

8to. New York, 1893 Academy. 
Obstbtbical Socibtt (Edinbuboh) — 

Transactions, Session 1893-94, voL zix. 

8yo. Edin. 1894 Society. 
tol. xzxvi, 29 



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Presented by 
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8vo. Paris, 1894 Society. 

Det Ejobenhaykske Mbdicinske Selskabs For- 
handlinobr — 1883-94. 
Redigereb af Dr. J. V. Wichmann. 

8vo. Kjobenhayn, 1894 Exchange. 



JOURNALS. 

Clinical (The) Journal: a weekly record of Clinical 
Medicine and Surgery, edited by H. W. D. 
Cardew, vol. ii. 4to. Lond. 1893 The Editor. 

Clinical (The) Journal: a weekly record of Clinical 
Medicine and Surgery, edited by Fred. J. Smith, 
vol. iii. " 4to. Lond. 1894 The Editor. 

Medical Annual and Practitioner's Index : a work of 

Eeference for Medical Practitioners. Messrs. 

8vo. Bristol, 1894 Wright & Co. 

Teratologia: Quarterly Contributions to Antenatal 
Pathology with Reviews of the current Litera- 
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Tear-book of Treatment for 1894 : a critical review for 
Practitioners of Medicine and Surgery. 

8vo. Lond. 1894 Purchased. 



REPORTS. 

Hospitals — Guy's Hospital Reports; Third Series, Hospital 
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Middlesex Hospital Reports for 1892. 

8vo. Lond. 1894 Ditto. 

St. Bartholomew's Hospital Reports ; vol. xxix. 

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vol. iii. 4to. Baltimore, 1894 Ditto. 

Qesellschaft fur Qeburtsbilfe und Gjnakologie, Fest- 
schrift, zur Feier des fuDfzigjabigeu Jubilaums, 
herausgegeben von der Deutschen Gesellschaft 
fur Gjnakologie durch E. Ghrobak und J. 
Pfannenstiel. 

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Jahresbericht iiber die Fortscbritte auf dem Gebiete der 
GeburtshilCe und G3makologie, herausgegeben 
von Bichard Frommel, vii Jahi^ng, 1893. 

8vo. Wiesbaden, 1894 Dr. Frommel. 

Ltino-in Institutions — Fromce, Fonctionnement de la 
Maison d'Accouchements Baudelocque, Gliuique 
de la Faculte, dirig^e par Adolpbe Pinard. Ann^ 
1893. 4to. Paris, 1894 Dr. Pinard. 

Oemumy, Berichte und Arbeiten aus der Uni- 

versitats-Frauenklinik zu Dorpat, von O. Kustner. 

plates, 8vo. Wiesbaden, 1894 Purchased. 

Arbeiten aus der koniglichen Frauen- 

klinik in Dresden, von G. Leopold. Band ii. 

8vo. Leipzig, 1894 Ditto. 



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